Florida Workers’ Compensation

Florida Workers’ Compensation Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C. 2016 Edition

Effective July 1, 2017

Florida Workers’ Compensation Health Care Provider Reimbursement Manual

TABLE OF CONTENTS CHAPTER 1 INTRODUCTION AND OVERVIEW.................................................... 6 Overview------------------------------------------------------------------------------------------------------- 6 E-Alert System ----------------------------------------------------------------------------------------------- 6 How to Obtain or Purchase Manuals -------------------------------------------------------------------- 7 Characteristics of the Manual----------------------------------------------------------------------------- 8 Identifying New Material ---------------------------------------------------------------------------------- 9 Health Care Provider Use of Codes, Descriptions and Modifiers -------------------------------- 12 Carrier Use of Codes, Descriptions, and References ------------------------------------------------ 12 General Reimbursement Information ------------------------------------------------------------------ 15 Co-Payments ------------------------------------------------------------------------------------------------- 15 General Reimbursement Information, continued ---------------------------------------------------- 17 Exceptions to Service Limitations ----------------------------------------------------------------------- 18 Disputing Reimbursement -------------------------------------------------------------------------------- 19 Classification of an Injured Worker’s Status --------------------------------------------------------- 20

CHAPTER 2 MEDICAL SERVICES........................................................................... 22 Anesthesia Services ----------------------------------------------------------------------------------------- 22 Biofeedback Services --------------------------------------------------------------------------------------- 27 Dental Services ---------------------------------------------------------------------------------------------- 28 Electrodiagnostic Medicine ------------------------------------------------------------------------------- 29 Evaluation and Management Services ----------------------------------------------------------------- 30 Functional Capacity Evaluations (FCE) --------------------------------------------------------------- 31 Home Health Agency Services --------------------------------------------------------------------------- 32

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Independent Medical Examinations -------------------------------------------------------------------- 33 Failure to Appear for IME-------------------------------------------------------------------------------- 34 Consensus Independent Medical Examination ------------------------------------------------------- 34 Medications -------------------------------------------------------------------------------------------------- 34 Medical Supplies and Home Medical Equipment ---------------------------------------------------- 39 Ophthalmologic Services ---------------------------------------------------------------------------------- 40 Permanent Impairment Ratings (PIR) ----------------------------------------------------------------- 40 Psychiatric and Psychological Services ----------------------------------------------------------------- 41 Radiology ----------------------------------------------------------------------------------------------------- 43 Thermography ---------------------------------------------------------------------------------------------- 44 Physical Medicine and Rehabilitation Services ------------------------------------------------------- 45 Acupuncture ------------------------------------------------------------------------------------------------- 51 Orthotics and Prosthetics --------------------------------------------------------------------------------- 52 Tests and Measurements ---------------------------------------------------------------------------------- 53 Physical Reconditioning Services ------------------------------------------------------------------------ 54 Physical Reconditioning Program ----------------------------------------------------------------------- 55 Chapter 2 Medical Services, continued ---------------------------------------------------------------- 56 Surgical Services -------------------------------------------------------------------------------------------- 59

CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES .......................... 68 CHAPTER 4 BILLING INSTRUCTIONS AND FORMS ....................................... 410 Bill Submission/Filing and Reporting Requirements --------------------------------------------- 410 Form DFS-F5-DWC-9 (CMS-1500) ------------------------------------------------------------------- 412 Form DFS-F5-DWC-10 ---------------------------------------------------------------------------------- 414

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APPENDIX A: WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES ......................................................................................................................................... 415 APPENDIX B OFFICIAL SOURCE FOR REFERENCES.................................... 416 APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ................ 419 APPENDIX D FORMS................................................................................................ 420 APPENDIX E DEFINITIONS ..................................................................................... 421

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Chapter 1 Introduction and Overview 0B

Overview Changes to the Manual 4B

Reimbursement Manuals will be available under the ‘Reimbursement Manuals’ section on the DWC website. It is important that health care providers (HCPs) and carriers read the updated material in the Manual. Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers.

E-Alert System 5B

The Division of Workers’ Compensation has an electronic alert system to notify subscribers of upcoming news impacting the Workers’ Compensation industry, dates of public meetings and workshops. To subscribe to the “E-Alerts”, please go to the DWC website. Look for the box entitled “Register”. Once registered, you will receive E-Alerts whenever they are provided by the Division.

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Chapter 1 Introduction and Overview, continued Overview, continued Preface

This Chapter introduces the format used for the Florida Workers’ Compensation Health Care Provider Reimbursement Manual and tells the reader how to use the Manual.

Background

There are 3 types of Workers’ Compensation Manuals:   

Other Applicable Rules

Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers, [ASC Manual], Rule 69L-7.100, Florida Administrative Code (F.A.C.); Florida Workers’ Compensation Health Care Provider Reimbursement Manual, [HCP RM], Rule 69L-7.020, F.A.C.; and Florida Workers’ Compensation Reimbursement Manual for Hospitals, [Hospital Manual], Rule 69L-7.501, F.A.C.

In addition to this Manual, the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C., also recognizes the following resource: 1. The Workers’ Compensation Medical Reimbursement and Utilization Review, Rule Chapter 69L-7, F.A.C., and 2. Selected Materials Incorporated by Reference For Use In Workers’ Compensation, Rule Chapter 69L-8, F.A.C.

How to Obtain or Purchase Manuals 6B

2016 Edition

This Manual can be obtained free of charge on the DWC website, under ‘Reimbursement Manuals’ or may also be purchased in hard copy from the Department of Financial Services, Document Processing Section, at 200 East Gaines Street, Tallahassee, Florida 32399-0311.

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Chapter 1 Introduction and Overview, continued Purpose

The purpose of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual (FL WC HCPRM) is to furnish health care providers with the policies and procedures needed to report services rendered to injured workers, and to file medical bills to carriers or selfinsured employers for reimbursement of services rendered. The FL WC HCPRM also provides carriers or self-insured employers the schedule of maximum reimbursement allowances approved by the Three-Member Panel for reimbursing health care providers for medically necessary care and treatment. The Manual provides descriptions and instructions on how and when to complete forms and other documentation that will assist in the medical bill filing process, as well as how to apply the reimbursement methodology for the schedule of Maximum Reimbursement Allowances (MRAs) to assist in the proper reimbursement of billed services.

Characteristics of the Manual 7B

Format

The format styles used in the Manual represent a concise and consistent way of displaying complex, technical material.

Information Block

Information Blocks replace the traditional paragraph and may consist of one or more paragraphs about a portion of a subject. Blocks are separated by horizontal lines. Each block is identified or named with a label.

Label

Labels or names are located in the left margin of each information block. The labels identify the content of the block in order to facilitate scanning and locating information quickly.

Note:

Note: is used most frequently to refer the user to pertinent material located elsewhere in the Manual, related Rules, specific statutory authority or to exceptions and limitations to a policy.

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Chapter 1 Introduction and Overview, continued How Changes Are Updated

Identifying New Material 8B

The Manual will be updated as needed. When a Manual is updated, the resulting new Manual will be replaced with a new effective date at the bottom of each page of the Manual. New Material will be identified by vertical lines. The following information blocks give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated.

New Label

A new label for an existing information block will be indicated by a vertical line to the left and right of the label only.

New Label and New Information Block

A new label and a new information block will be identified by a vertical line to the left and right of the label and the information block.

New Material in an Existing Information Block

A paragraph within an existing information block that has new or changed material will be indicated by a vertical line to the left and right of the paragraph. Paragraph with new material will be indicated in this manner. Existing material New material within a list will be indicated in this manner.

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Chapter 1 Introduction and Overview, continued Administrative Purpose of the Manual

The administrative purpose of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2016 Edition, is to furnish health care providers, as defined in subsection 440.13(1), F.S., with general information, billing and reimbursement policies, and Maximum Reimbursement Allowances (MRAs) for covered services and procedures.

Prior Authorization of Services

Health care providers and out-of-state providers must have authorization by the Workers’ Compensation carrier or a self-insured employer prior to:  

Rendering initial care, remedial medical services; and pharmacy services, or Making a referral for the injured worker to facilities or other health care providers.

Note: Exceptions to prior authorization are:   

Notification of Emergency Treatment

Federal facilities; Emergency room services and care, defined in section 395.002, F.S.; or A provider referral for emergency treatment resulting from emergency services.

Any health care provider who renders emergency care must notify the carrier, in writing or by facsimile, by the close of the third business day after care has been rendered. If the emergency care results in admission to a health care facility, the health care provider must notify the carrier by telephone within 24 hours after initial treatment.

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Chapter 1 Introduction and Overview, continued Carrier Responsibilities at Authorization

An carrier is responsible for meeting its obligations under this Rule regardless of any business arrangements with any service company/TPA, submitter or any entity acting on behalf of a carrier which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division. At the time of authorization for medical service(s), a carrier must notify each health care provider, in writing, of additional form completion requirements or supporting documents that are necessary for reimbursement and provide the specific address for submitting a reimbursement request. At the time of authorization for medical service(s), a carrier must inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Rule and provide the specific address for submitting a reimbursement request.

Fraud Statement

A health care provider involved in the process of making a claim under the Workers’ Compensation Program must provide his or her personal signature once per calendar year attesting that he or she has reviewed, understands, and acknowledges the following statement: “Any person who, knowingly and with intent to injure, defraud, or deceive any employer or worker, insurance company, or self-insured program, files a statement of medical bill containing any false or misleading information commits insurance fraud, punishable as provided in section 817.234, F.S.”

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Chapter 1 Introduction and Overview, continued Health Care Provider Use of Codes, Descriptions and Modifiers 9B

Physicians and other health care providers must use the codes and descriptions, modifiers, policies, definitions and instructions of the referenced CPT®, CDT®, HCPCS®, ICD-10® or Florida Workers’ Compensation unique codes or other materials referenced in Rules 69L-8.071 and 69L-8.074, F.A.C. and: 

The Minnesota Department of Labor and Industry Disability Schedule, as adopted in Rule 69L-7.604, F.A.C.;  The Florida Impairment Rating Guide, as adopted in Rule 69L-7.604, F.A.C.;  The 1996 Florida Uniform Permanent Impairment Rating Schedule, as adopted in Rule 69L-7.604, F.A.C.; and  The American Medical Association’s Guide to the Evaluation of Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C

The use of HCPCS® Level II codes is allowed only when there is not a more specific CPT® code available for use. All diagnosis codes must be reported at the highest level of specificity according to the ICD-10-CM® valid number of digits, i.e., seven (7) digits where noted in the ICD-10-CM® manual. Both ICD-9 and ICD-10 codes may not be reported on the same claim form.

Carrier Use of Codes, Descriptions, and References 10B

Carriers must use the codes and descriptions, modifiers, policies, definitions, and instructions of the referenced CPT®, CDT®, HCPCS®, ICD-10 or Florida Workers’ Compensation Unique Codes on the medical bill prior to making reimbursement decisions. In addition, where not inconsistent with instructions in this Manual, carriers may utilize the National Correct Coding Initiative (NCCI) edits in effect on the date(s) of service as part of the bill review process.

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Chapter 1 Introduction and Overview, continued Notice of Privacy Practices

Every health care provider and other recognized health care practitioner will, except in emergency treatment situations, make a good faith effort to obtain a written acknowledgement of receipt of notice of privacy practices no later than the first day of providing medical services to a workers’ compensation insured patient. If not obtained, document its good faith efforts to obtain such acknowledgement and the reason why the acknowledgement was not obtained. In the event a patient, guardian, curator, or personal representative requests restriction(s) of the use or disclosure of identifiable health information that would prevent disclosure as necessary for treatment or payment for health care services, the provider or other recognized health care practitioner must notify the carrier immediately, if possible, or by close of business on the next regular business day.

Disclosure to Carriers

Unless instructed otherwise, it is the responsibility of all health care providers to furnish, without charge, the following documentation to the carrier:  A complete report of the patient’s symptoms, findings and plan of treatment pursuant to reporting requirements of the DFS-F5-DWC-25;  An operative report when a surgical procedure is performed;  A narrative report when a consultation or an independent medical examination is rendered;  Copies of medical records, when requested at the time of authorization by the employer/carrier or designated entity, in order to determine the medical necessity of services that must be substantiated in more detail than previously disclosed;  A copy of the DFS-F5-DWC-25 associated with the recommended or rendered care or treatment.  Failure of the health care provider to forward information when requested by the carrier may result in the billed service being disallowed or denied payment until sufficient documentation is provided to render the necessary determination. Moreover, a health care provider’s failure to release medical records or information upon a reasonable request or to release full and truthful medical reports of all of his or her findings will constitute a violation of Chapter 440, F.S., subject to penalties imposed by the Division.

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Chapter 1 Introduction and Overview, continued Disclosure to Workers

A health care provider, upon request, must furnish the injured worker, injured worker’s attorney, the employer or carrier or its attorney, on demand, relevant portions of his or her office chart, records, and reports. The relevant portions sought must be related to the particular injury or illness for which compensation is sought.

Injured Worker’s Requests

A health care provider may charge an injured worker or their representatives no more than $0.50 per page for copies of written medical records. The relevant portions of the medical record sought must be related to the particular injury or illness for which compensation is sought. Payment must be made to a health care provider by the requesting party at the provider’s actual cost for x-rays, microfilm, or other non-written records.

Carrier’s Requests

A health care provider, upon request, must provide a copy of the injured worker’s medical records to a carrier or carrier’s representative or attorney. A health care provider, upon request, must furnish a carrier or the carrier’s attorney a copy of the injured worker’s medical chart, records and reports. A health care provider, upon request, must furnish the carrier or the carrier’s attorney, non-written medical records.

Division or Judge of Compensation Claims Requests

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A health care provider, upon request, must provide medical records to the Division or a Judge of Compensation Claims without charge.

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Chapter 1 Introduction and Overview, continued General Reimbursement Information 1B

Billing the Injured Worker

Co-Payments 12B

Health care providers must not bill the injured worker for services rendered for a compensable work-related injury except when it is to collect a co-payment fee or when apportioning out the percentage of need for the care attributable to a pre-existing condition. A health care provider is entitled to collect a co-payment of $10.00 per visit when providing medical services and care to an injured worker who has reached overall maximum medical improvement (MMI).   

Federal Facilities

Co-payments may only be collected for evaluation and management visits after the injured worker has received an assignment of MMI. The co-payment will not apply to emergency care or services provided to the worker; and The co-payment is not in addition to the maximum reimbursement allowance or fee agreement. The reimbursement amount otherwise payable by the carrier will be reduced by the amount of the co-payment.

Federal facilities are exempt from the reimbursement provisions and allowances in this Manual. A carrier must reimburse a federal facility its usual charge.

Florida Health Care Providers

Reimbursement will be made to a Florida health care provider after applying the appropriate reimbursement policies contained in this Manual. A carrier will reimburse a health care provider either the MRA in the appropriate reimbursement schedule or a mutually agreed upon contract price. Note: See Chapter 3 for MRAs and instructions on how to determine the correct MRA.

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Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued Out-of-State Providers

Prior to the delivery of medical services, a carrier and health care provider must agree upon the amounts of reimbursement for the services at the time of authorization; or If no agreement is made prior to the service being rendered, the carrier will reimburse the greater of either: 1. The MRA according to the out-of-state fee schedule for the services provided; or 2. The MRA according to Chapter 3 Part A of this Manual.

Codes Paid by MRAs

Reimbursement for procedure codes listed in this Manual with an MRA will be at the maximum reimbursement allowance after the application of any reimbursement policies contained in this Manual. When the billed charge is less than the MRA, the reimbursement will be the MRA amount in the Fee Schedule. Note: The only exception is when there is a clearly defined reimbursement amount between the health care provider and carrier provided in a contractual agreement.

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Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued 13B

Codes Paid By Report (BR)

Reimbursement will be determined by the carrier for procedure codes listed in the Fee Schedule as By Report (BR). Payment will be based on a provider’s documentation submitted to the carrier containing information on the complete description of the service or procedures actually performed, medical necessity, and cost of any additional supplies. At a minimum, reimbursement will be: 

The Florida Workers’ Compensation MRA for clinically similar procedure codes in the current fee schedule.

The health care provider must submit the required documentation to the carrier when the following situations occur:  

The procedure code’s MRA is listed in the Fee Schedule as BR in Chapter 3 of this Manual; or There is a valid procedure code in the CPT® or the HCPCS® Level II Manual which corresponds to the date of service. The billed procedure code cannot be listed in this Manual.

Note: See Codes with No MRAs later in this Chapter.

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Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued Codes with No MRAs

Carriers must have an established methodology for determining reimbursement for procedure codes that have no established MRAs, unlisted procedure codes, and codes that are paid By Report. Carriers must utilize the expertise of peer review physicians for concurrent review, including the appropriateness and cost of the medical services reported; billing and coding issues; and determining reimbursement.  Carriers will determine reimbursement by comparing the billed procedure code(s) with clinically similar procedure code(s) found in the appropriate CPT or HCPCS Manual; and  Carriers will make reimbursement decisions based on all of the provider’s documentation, the carriers medical bills, relative value data, services and supplies and peer physician recommendations; and  Carriers will reimburse all work-related and medically necessary services provided in a documented medical or dental emergency. This reimbursement methodology must also be available in response to any Petition for Reimbursement Dispute or upon request by the Division.

Reimbursement for Failed Appointments

Reimbursement is not made for failed appointments. Note: This exclusion does not apply to Independent Medical Examinations pursuant to paragraph 440.13(5)(d), F.S. See Independent Medical Examination in Chapter 2.

Exceptions to Service Limitations 14B

When a health care provider deems it medically necessary in the treatment of an injured worker’s injury or illness to furnish medical services that exceed the number of services in reimbursement policies in this Manual, a health care provider must:  

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Submit documentation to the carrier substantiating the medical necessity for the request; and Receive specific written authorization from the carrier to render the requested additional services before they are provided.

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Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued Services Unrelated to the Compensable Injury

Disputing Reimbursement 15B

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Carriers will not reimburse health care provider charges for services unrelated to the treatment or care of a compensable injury except when the treatment is required to stabilize or maintain the patient’s medical status in order to treat the patient’s compensable injury or condition.

The health care provider may elect to contest the disallowance or adjustment of payment under subsection 440.13(7), F.S. The election to contest the disallowance or adjustment of payment under subsection 440.13(7), F.S., must be made by the health care provider within forty-five (45) calendar days of receipt of the Explanation of Bill Review (EOBR) or notice of disallowance or adjustment of payment.

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Chapter 1 Introduction and Overview, continued Classification of an Injured Worker’s Status 16B

General Policies

Providers are to utilize the Workers’ Compensation specific patient classification levels when submitting the required treatment status on the DFS-F5-DWC-25 to the carrier.

Classification System

The following best describes the patient classification levels are:   

Purpose of Proper Patient Classification

Proper classification of the patient is intended to:     



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Criteria based. Comprised of descriptive categories to provide a means to promote decision-making, accountability and responsible medical bill handling practices. Neither hierarchical nor severity indicators.

Convey to carriers the complexity of services that may be required for optimal clinical management; Distinguish the overall critical differences among cases that influence the intensity, scope, and cost of services provided; Facilitate recognition of three varying clinical configurations that affect the medical treatment plan and treatment progress or other available benefits for an injured worker; Assist the carrier in decisions related to authorization of recommended treatment plans or treatment plan revisions; Ensure that on-going treatment plans and authorized reimbursable services are consistent with the high intensity, short duration treatment approach which focuses on specific clinical dysfunction before authorization is made to a provider. Enhance communication between the provider and the carrier to facilitate the authorization process for the provision of medically necessary care.

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Chapter 1 Introduction and Overview, continued Classification of an Injured worker Status, continued Patient Classification Levels

Level I: Key issue – specific, well defined medical condition, with clear correlation between objective relevant findings and patient’s subjective complaints. Treatment correlates to specific findings. Level II: Key issue- regional or generalized de-conditioning (i.e., deficits in strength, flexibility, endurance, and motor control). Treatment includes physical reconditioning or functional restoration. Level III: Key issue – poor correlation between patient’s complaints and objective, relevant physical findings, both somatic and non-somatic clinical factors. Treatment includes interdisciplinary management and rehabilitation.

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Chapter 2 Medical Services Anesthesia Services 17B

Reimbursable Providers

Anesthesia services are reimbursed to anesthesiologists, certified registered nurse anesthetists (CRNAs) and anesthesia assistants (AAs) practicing within the scope of state licensure. A surgeon may also be reimbursed for anesthesia services performed during surgery.

Anesthesia Minutes

Anesthesia time begins when the provider starts to prepare the injured worker for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance, that is, when the injured worker may be safely placed under postoperative supervision. Note: Anesthesia time must be billed as the total number of minutes of anesthesia. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as seventy-five (75) minutes of anesthesia.

Anesthesia Time Units

The minutes of anesthesia must be converted by the carrier into time units as follows: 1. For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) time unit and each minute over a time unit has a value of onetenth (1/10) time unit. 2. For CRNAs or AAs, each fifteen (15) minutes of anesthesia time equals one (1) time unit and each minute over has a value of one-fifteenth (1/15) time unit.

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Chapter 2 Medical Services, continued Anesthesia Services, continued Physical Status Modifiers

Anesthesia services will warrant additional reimbursement for units based upon the injured worker’s condition and the complexity of the anesthesia service provided. A physical status modifier will be determined by the provider (CRNA or anesthesiologist only) to rank the injured worker’s condition. Additional reimbursement will be based on the unit value for the specific physical status modifier, as assigned by the CPT® Manual. A physical status modifier is required for billing and reimbursement of anesthesia bills. Physical Status Modifiers P1 A normal healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is a constant threat to life P5 A moribund patient who is not expected to survive without the operation P6 A declared brain dead patient whose organs are being removed for donor purposes

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Unit Values 0 0 1 2 3 0



Chapter 2 Medical Services, continued Anesthesia Services, continued Difficult or Qualifying Circumstances

Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. Listed below are the specific qualifying circumstances, as assigned by the CPT® Manual, that impact the anesthesia services provided. These procedure codes are not to be reported alone, but are reported as additional procedure codes. The listed unit value must be added to the base value units to calculate the reimbursement. List each of the following codes below the primary anesthesia procedure code on the billing form. Code 99100 99116 99135 99140

Unit Value Anesthesia for patient of extreme age, under one year and over seventy Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypothermia Anesthesia complicated by emergency conditions (specify) All others

Calculation of Anesthesia Reimbursement

1 5 5 2 0

Select the applicable anesthesia procedure code and note the base value from the fee schedule in Chapter 3, Part A, of this Manual. Determine the time units based on provider type. Determine any additional units that are justified by the physical status modifier and qualifying circumstances. Add the base value, time units, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value. Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement. Base Value (BV) Time Units (TM) Physical Status modifier units + Qualifying Circumstances Units = Total Anesthesia Units Total Anesthesia Units x $29.49 = $ Reimbursement

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Chapter 2 Medical Services, continued Anesthesia Services, continued Procedures Listed as BV with No TM Units

Certain anesthesia services do not have a listed time value component. The reimbursement method for an anesthesia services that does not have time units associated with the anesthesia base value is as follows:    

Select the applicable anesthesia procedure code and base value from the schedule in Chapter 3, Part A of this Manual. Determine any additional units that are justified by the physical status modifiers or qualifying circumstances. Add the base value, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value. Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement.

Base Value Physical Status Modifier units + Qualifying Status units = Total Anesthesia Units Total Anesthesia Units x $29.49 = $ Reimbursement Note: CRNAs and AAs reimbursement will be limited to 85% of the total anesthesia reimbursement allowance for an anesthesiologist for any procedure that has no TM units.

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Chapter 2 Medical Services, continued Anesthesia Services, continued Medical Direction of CRNA/AA by Anesthesiologist

Reimbursement will only be made to the anesthesiologist for the direct supervision of anesthesia services which are provided by the anesthesiologist and billed under the name and license number of the physician. Reimbursement will be made to an anesthesiologist for providing medical direction, including pre-operative and post-operative evaluations or specific consultations to a CRNA/AA as previously identified by the specific protocol. Reimbursement for a CRNA/AA requiring medical direction by an anesthesiologist will be fifty percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3, Part A or the agreed upon contract price. Reimbursement for medical direction by an anesthesiologist will be fifty percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3, Part A of this Manual or the agreed upon contract price. Reimbursement will not be made to either the anesthesiologist or the CRNA/AA until the carrier has received and reviewed the medical bills and anesthesia reports from both providers. No additional reimbursement will be made for general supervisory services rendered by the anesthesiologist.

Special Billing Requirements for Anesthesia

All anesthesia services must be billed on Form DFS-F5-DWC-9. Anesthesia services must include the CPT® code and the “P” code (physical status modifier) which corresponds with the procedure performed in Field 24D. 1. Anesthesia providers must enter the date of service and the 5 digit qualifying circumstances code, which corresponds with the procedure performed, in Field 24D on the next line, if applicable. 2. Medical direction must be billed by the anesthesiologist by adding the HCPCS® Level II modifier QY to the anesthesia procedure code. 3. When medical direction is required, the CRNA or AA must bill by appending the HCPCS® Level II modifier QX to the anesthesia procedure code. The CRNA or AA must provide his or her Florida Department of Health (DOH) license number in Field 33b. 4. When a Certified Registered Nurse Anesthetist provides anesthesia services, the CRNA must enter his/her Florida Department of Health (DOH) license number in Field 33b. Note: See Rule 69L-7.730(2), F.A.C.

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Chapter 2 Medical Services, continued Anesthesia Services, continued Anesthesia Performed by a Surgeon

When a surgeon provides regional or general anesthesia for a surgical procedure that he or she actually performs, modifier 47 is appended to the anesthesia procedure code to indicate that the operating surgeon performed the anesthesia. An operating surgeon cannot report time units in the calculation of anesthesia reimbursement request on the medical bill. Reimbursement will be for the base value (BV) multiplied by the anesthesia conversion factor only for the anesthesia service rendered. Base Value x $29.49 (anesthesia CF) = $ Reimbursement Note: See Chapter 3, Part A of this Manual for anesthesia Base Values.

Biofeedback Services 18B

Requirements for Reimbursement

Reimbursement for the collection and interpretation of biofeedback data digitally stored and downloaded will be included in the reimbursement to the provider for the basic biofeedback service. The written interpretation of the digitally stored biofeedback results must be signed and dated by the health care provider and maintained in the medical record.

Limitations to Biofeedback Services

Reimbursement for biofeedback training will be limited to twelve (12) visits per date of injury. Note: This biofeedback training limitation does not include individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy.

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Chapter 2 Medical Services, continued Dental Services 19B

Reimbursable Providers

All dental services must be authorized by a carrier before the services are rendered. A carrier will only reimburse a dentist or an oral surgeon for authorized services. Note: Emergency oral surgery does not require prior authorization. The carrier must be notified by the provider no later than the close of the third business day after emergency treatment.

Dental Codes and Descriptions

Dentists must use the dental guidelines, codes and descriptors from the CDT® or the D codes in the HCPCS® for dental procedures. Dental services are billed on Form DFS-F5-DWC-11.

Oral Surgery

Oral Surgeons must use the CPT® guidelines, codes, descriptors and modifiers for oral and maxillofacial surgical services. Oral surgery services are billed on the DFS-F5-DWC-9 medical bill form. Note: Oral Surgeons will refer to the label block “Billing and Reimbursement of Multiple Surgical Procedures” under Surgical Services in this Manual for information regarding reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines.

Temporomandibular Joint (TMJ) Services

Dentists must bill using a combination of the dental guidelines, codes and descriptors from the CDT® manual and the D codes from the HCPCS® manual.  

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Dentists who provide TMJ services may use a combination of CPT® codes and dental codes from the CDT® or HCPCS®. Dentists will refer to the physical medicine section of this Manual for information on physical medicine reimbursement policies.

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Chapter 2 Medical Services, continued Dental Services, continued Reimbursement to Dentists and Oral Surgeons

Reimbursement to a dentist or oral surgeon for dental procedures or services will be the MRA or the agreed upon contract price. Note: See Chapter 3 for the MRAs for Dentists and Oral and Maxillofacial Surgeons in this Manual.

Electrodiagnostic Medicine 20B

Determining Medical Necessity

The referring physician must determine the medical necessity of an electromyography (EMG) or a nerve conduction study (NCS). Only a physician will determine the frequency of testing or the necessity of repeat testing.

Needle Electromyography (EMG)

Only a physician or a recognized practitioner specifically qualified by regulations in the state where the service is provided will be reimbursed for needle EMG testing. Reimbursement must include the testing, interpretation of the studies and a written report of the findings.

Reimbursement Policies for EMG

When the initial evaluation and management service and needle EMG testing are performed during the same visit, reimbursement will be made for both services. When a follow-up evaluation and management service and needle EMG testing are performed on the same day, reimbursement will be made to a physician for both services if the physician’s documentation validates the medical necessity for the follow-up evaluation and management service. When needle EMG testing is performed in a hospital or other facility, reimbursement will be made to a physician for an interpretation and report of the testing. Modifier 26 must be appended to the appropriate procedure code for reimbursement.

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Chapter 2 Medical Services, continued Electrodiagnostic Medicine, continued Nerve Conduction Studies (NCS)

Only physicians or recognized practitioners specifically qualified by state regulations to perform Nerve Conduction Studies (NCS) will be reimbursed. A physician or a recognized practitioner specifically qualified by regulations in their state will determine the nerves to be tested based on specific clinical findings during the examination performed at the time of the study will be reimbursed if authorized by the carrier for an NCS.

Reimbursement Policies for NCS

When the initial evaluation and management service and the NCS are performed during the same visit, reimbursement will be made for both services. When a follow-up evaluation and management service and NCS are performed on the same day, reimbursement will be made for both services only if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service subsequent to findings from the initial visit. A technologist under the direct supervision of the physician may perform a NCS. However, the services must be billed under the name and Florida Department of Health license number of the supervising physician or out-ofstate license number. Reimbursement will include the testing, interpretation of the studies and a written report of the findings.

Evaluation and Management Services 21B

Office Visits

A carrier will reimburse a physician for evaluation and management services (new or established patient visits). A new patient means an injured worker who is new to the health care provider or an established patient with a new compensable injury or illness and a new date of accident. Note: Reimbursement is limited to one (1) visit per day at the level of care documented by the physician.

2016 Edition

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Chapter 2 Medical Services, continued Evaluation and Management Services, continued Consultations

A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate resource. A physician will be reimbursed for consultations, confirmatory consultations and follow-up consultation services. Reimbursement will include a review of all submitted medical records, paper and non-paper; an examination of the injured worker; and a written report.

Home Visit Services

A physician will be reimbursed for home visits when authorized by the carrier. A physician must bill with the appropriate evaluation and management procedure code for a home visit to bill the service.

Functional Capacity Evaluations (FCE) 2B

Reimbursement Criteria

All FCE protocols must be evidence-based. Test design and written interpretation must, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e., correlate impairment with disability). Reimbursement for an authorized FCE will be made at any time in the clinical continuum (see Patient Classification System in Chapter 1 of this Manual), as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s). Reimbursement will be made for the CPT® code 97750, specifically designated for use solely in reporting a FCE. The reimbursement for a FCE includes a written program plan and a written report. The provider must provide the results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge. Reimbursement for an FCE will be made only when a physical therapist or occupational therapist is directly and actively involved with the testing protocol, although additional professional personnel may be involved as well. Note: Bill using CPT® code 97750.

2016 Edition

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Chapter 2 Medical Services, continued Home Health Agency Services 23B

Definition

Home Health Services are medically necessary services which can be effectively and efficiently provided in the place of residence of an injured worker. Services include home health visits (nurses and home health aides), therapy services (speech therapy, physical therapy, occupational therapy), and authorized home medical equipment.

Home Health Visit Definition

A Home Health Visit is a face-to-face encounter between a registered nurse, licensed practical nurse, home health aide, or licensed therapist employed by a Home Health Agency and an injured worker at his or her place of residence. A Home Health Visit is not limited to a specific length of time, but is defined as an entry into the injured worker’s place of residence for the length of time needed to provide the medically necessary nursing, home health aide, or therapy service(s). An injured worker’s residence cannot be in a facility such as a hospital, a nursing facility, or a rehabilitation facility of any type.

General Policies

A Home Health Agency must have a signed order outlining the Home Health Plan of Care from the authorized, treating physician in order to obtain carrier authorization of home health services. The Home Health Plan of Care must be renewed every thirty (30) calendar days and submitted to the carrier for approval before further services may be authorized by the carrier.

Treating Physician

The authorized treating physician is the doctor responsible for the management and treatment of the injured worker’s compensable medical condition or the physician assigned by the Judge of Compensation Claims to treat the injured worker for the compensable condition. The treating physician cannot be a consulting physician unless there has been a complete transfer of care.

Authorization

A Home Health Agency must obtain authorization from the carrier prior to assigning any licensed health care employees to render services in an injured worker’s residence. A Home Health Agency is required to obtain a separate, written or electronic authorization from the carrier for any Home Medical Equipment needed. The carrier’s authorization to provide home health services does not authorize home medical equipment and supplies unless such authorization is expressly stated.

2016 Edition

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Chapter 2 Medical Services, continued Home Health Agency Services, continued Staff Skill Level

A Home Health Agency must provide staff with the skill level designated and appropriate for each service prescribed in the treating physician order and approved plan of care as authorized by the carrier.

Staff Substitutions

If a staff absence occurs, the Home Health Agency is responsible for providing and assuring that appropriate staff substitutions are made. Licensure or discipline of the staff substitutions must be equivalent to, or above, the discipline level as specified in the plan of care.

Reimbursement

The carrier will reimburse the Home Health Agency at the reimbursement amounts mutually agreed upon between the Home Health Agency and the carrier in a contract prior to the services being delivered in the home.

Billing for Home Health Agency Services

The Home Health Agency must bill on the Form DFS-F5-DWC-90 and include a copy of their contractual agreement with the billing form to the carrier for proper reimbursement. When a Home Health Agency is billing for authorized DME, on the Form DFS-F5-DWC-90, a copy of the treating physician’s original order for the DME item(s) must accompany the bill submitted to the carrier.

Independent Medical Examinations 24B


Reimbursement for IME

Reimbursement for an Independent Medical Examination (IME) shall include:   

The review of applicable paper medical records; The review of non-paper medical records; and The examination of the injured worker with production of a written report.

A physician will be reimbursed by the party requesting the IME. IME services are reimbursed at either the MRA or a mutually agreed upon contract amount. Note: The only procedure code for billing an IME is the Workers’ Compensation Unique code 99456.

2016 Edition

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Chapter 2 Medical Services, continued Failure to Appear for IME 25B

If an injured worker fails to appear for an IME, scheduled by the employer or carrier, without good cause and failed to advise the physician at least 24 hours before the scheduled date for the examination that he or she will not appear, the physician may bill his or her cancellation or no-show fee to the carrier. Note: The physician must bill using the Workers’ Compensation unique code 99456 CN to indicate the injured worker failed to appear or the appointment was canceled without proper notice.

Consensus Independent Medical Examination 26B


Reimbursement for a Consensus Independent Medical Examination (CIME) must include: 1. The review of applicable paper and non-paper medical records; 2. An examination of the injured worker including determination of Maximum Medical Improvement (MMI); 3. Assignment of a permanent impairment rating, as appropriate; and 4. A written report.

Reimbursement for CIME

Reimbursement for a CIME will be negotiated between the physician and the carrier prior to rendering the service. A physician will be reimbursed by the carrier for a CIME. Note: CIME service must be billed with the Workers’ Compensation Unique code 99457 for reimbursement.

Medications 27B

General Policies

Medicinal drugs, commonly known as legend or prescription drugs, dispensed to treat an injured worker must be ordered by a physician or other recognized health care practitioner and authorized by the carrier. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter 465, F.S., or a licensed dispensing practitioner according to the provisions in section 465.0276, F.S.

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Chapter 2 Medical Services, continued Medications, continued Codes and Descriptions for Medications

Physicians and other recognized practitioners must refer to the HCPCS® manual in effect for the date of service when reporting injection procedures, as well as immune globulin, or vaccine products. Providers must use the J codes in the HCPCS® Level II Manual, as adopted in Rules 69L-8.071 and 69L-8.074, F.A.C., for reporting other injectable medications. If the specific medication is not listed in either of these references, the provider must bill the medication using the National Drug Code (NDC) number for reimbursement.

Reimbursement for Injectable Medications

2016 Edition

Reimbursement for injectable medications will be made to a health care provider as follows: 

Reimbursement shall be made to a health care provider using CPT® or HCPCS® J codes for specific injectable medications and CPT® codes for the administration of injectable medications.



Reimbursement will be at either the contract price or the listed MRA in the appropriate schedule.



Reimbursement for an injection will include a local anesthetic, if necessary.



Reimbursement for multiple medications administered from the same syringe will be: 

At either the contract price or the listed MRA, in Chapter 3, Part A of this Manual for the first reported drug; and



At either the contract price or fifty percent (50%) of the listed MRA in the appropriate schedule for each additional drug. Each additional drug must be reported by appending modifier 51 to the HCPCS® or CPT® code.

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Chapter 2 Medical Services, continued Medications, continued Reimbursement for Injectable Medications (continued)

Reimbursement to a physician for codes 90749 or J3490 will be twenty percent (20%) above the actual cost of the injectable medication based on submission of: 1. The name, strength and dosage of the medication, vaccine or toxoid; and 2. Documentation verifying the cost of the medication, vaccine or toxoid. 3. Applicable manufacturers Shipping and Handling will be reimbursed at the actual cost on the invoice.

Morphine via Infusion Pump

A special provision is allowed for identification of the loading dose of Morphine Sulfate administered via infusion pump. Providers must utilize an appropriate HCPCS® code if deemed by the practitioner to be the most appropriate coding option. Reimbursement will be twenty percent (20%) above the documented cost of the drug. Applicable manufacturer’s Shipping and Handling will be reimbursed at the actual cost on the invoice.

Dispensing Medications

The dispensing of medicinal drugs will be limited to a pharmacist or a licensed dispensing practitioner and billed under the NDC number. The reimbursement for prescription medications will be: Average Wholesale Price (AWP) + $4.18 = $ Reimbursement Note: see paragraph 440.13(12)(c), F.S., for the definition of Average Wholesale Price. For repackaged or relabeled prescription medications dispensed by a health care practitioner on or after date of service July 1, 2013, see paragraph 440.13(12)(c), F.S., to obtain the reimbursement of repackaged prescription medications. Note: See Rule Chapter 69L-7, F.A.C., for proper billing of repackaged or relabeled medications.

2016 Edition

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Chapter 2 Medical Services, continued Medications, continued Compounded Drugs

Medicinal drugs may be compounded by a pharmacist or a physician when the drug formulation prescribed is not commercially available. Dispensing compound drugs is identified as a specialty service under paragraph 440.13(3)(i), F.S. Compounded drugs may not have an NDC number.

Reimbursement for Compounded Drugs

The provision and reimbursement of compounded drugs will be limited to a pharmacist or a physician and is billed using the Workers’ Compensation unique procedure code COMPD, which represents all components of the compounded product. Reimbursement is the lesser of: 1. [AWP (of each component)] + $4.18 = Reimbursement; or 2. The amount the carrier has contracted for pursuant to paragraph 440.13(12)(c), F.S. Note: Please refer to paragraph 440.13(12)(c), F.S., for the definition of AWP.

Unlisted Medications

Reimbursement for unlisted medications with no MRA in Chapter 3 of this Manual, will be twenty percent (20%) above the actual cost of the medication based on the submission of documentation which includes:  

Over the Counter Drugs

2016 Edition

The name, strength, and dosage of the medication dispensed to the injured worker; and The invoice verifying the actual cost of the medication.

Reimbursement shall be made to a pharmacist for dispensing over-the-counter drugs at the pharmacist’s usual charge for the drug. A dispensing practitioner shall use the NDC number and submit an invoice to the carrier that provides the name, dosage, package size and cost of the drug(s), including applicable manufacturer’s Shipping and Handling. A pharmacist or dispensing practitioner may bill a dispensing fee if the drug is prescribed by the treating provider.

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Chapter 2 Medical Services, continued Over the Counter Drugs, continued

Reimbursement shall be made at the provider’s charge or at an amount not to exceed twenty percent (20%) above the actual cost of each drug furnished. Reimbursement shall not be made for oral vitamins, nutrient preparations or dietary supplements.

NonReimbursable Drugs and Supplies

Reimbursement will not be made for oral vitamins, nutrient preparations or dietary supplements. Reimbursement will not be made for medical food pursuant to paragraph 440.13(3)(k), F.S., as defined in 21 U.S.C s. 360ee (b) (3), unless the self-insured employer or the carrier in its sole discretion authorizes the provision of such food. Such authorization may be limited by frequency, type, dosage, and reimbursement amount of such food as part of a proposed written course of medical treatment.

Reimbursable Materials and Supplies

Reimbursement for supplies and materials not incidental to a service or a procedure will be reimbursed using the specific HCPCS® Level II supply codes.

Unlisted Supply Code

When a more specific code is not available for reimbursable supplies and materials, bill using the HCPCS® miscellaneous supply code A9999 and submit documentation with the following: 

A detailed description of the supply or material and the unique medical need for the injured worker; and



A copy of the actual invoice to document the cost of the item billed including unit(s) of supply and unit pricing information. If needed, please circle the items on any invoice that are specific to the injured worker when submitting the medical bill.

Supplies and Materials Not Separately Reimbursed

Material and supplies which are necessary to perform a procedure or provide a service will be included in the reimbursement for the procedure or service and will not be reimbursed separately.

Reimbursement for Supplies

Reimbursement will be limited to twenty percent (20%) above the actual invoice cost of the supply(s) based on submission of the documentation that substantiates the provider’s cost, including applicable manufacturer’s shipping and handling.

2016 Edition

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Chapter 2 Medical Services, continued Medical Supplies and Home Medical Equipment 28B

General Requirements

Medical supplies and home medical equipment must be prescribed by a physician and may be provided to an injured worker by a home medical equipment supplier through rental or purchase.

Authorization

A home medical equipment supplier must obtain a specific written or electronic authorization and a written payment agreement from the carrier prior to furnishing an injured worker with medical supplies or equipment.

Billing

A home medical equipment supplier must provide the carrier with a copy of the physician’s original order with the medical bill when requesting reimbursement. A home medical equipment supplier is required to bill on the Form DFS-F5-DWC-10 using HCPCS® codes. The home medical equipment supplier is not required to provide invoices with the bill to document the acquisition costs of supplies and equipment. Note: When no specific code is available to describe the item provided, bill using HCPCS® code A9999 unless specifically requested by the carrier at the time of authorization.

Reimbursement

Reimbursement will be made by the carrier to a home medical equipment supplier for rental or purchase of medical equipment and supplies ordered or prescribed by a physician or recognized practitioner according to the written payment agreement obtained at the time of authorization.  



2016 Edition

The carrier may rent the item from the supplier for the injured worker; or The carrier may write a provision in the payment agreement that when the amount received by the supplier from the rental payments equals the purchase price, the item will become the property of the carrier or injured worker; or The carrier may purchase the item from the supplier.

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Chapter 2 Medical Services, continued Medical Supplies and Home Medical Equipment, continued Limitations for Supplies and DME

No reimbursement will be made for supplies or equipment that are automatically supplied or refilled by the supplier. All services and refilled supplies require explicit carrier authorization as a requirement for reimbursement.

Ophthalmologic Services 29B

General Reimbursement Requirements

Reimbursement for ophthalmologic services will be made for all medically necessary services. Authorization from the carrier is required unless the condition is an emergency situation.

Glasses, Contacts or Frames

Reimbursement will only be made for glasses, contact lens, or frames of comparable quality to the original when they are damaged, lost or required for treatment as a result of an injury or surgery to correct an injury.

Permanent Impairment Ratings (PIR) 30B

Providers Eligible for Reimbursement

Only a physician licensed by the Chapters listed in paragraph 440.13(3)(b), F.S., will be reimbursed by the carrier for addressing maximum medical improvement (MMI) and the assignment of a Permanent Impairment Rating (PIR ).

Reimbursement Components and PIR

Reimbursement will include an examination to include: 1. Evaluation of an injured worker’s condition to include the establishment of the MMI date and PI rating of zero (0) percent or greater; and 2. The systematic completion of the required reporting form, Form DFS-F5DWC-25, and submission to the appropriate parties in accordance with s. 440.15(3), F.S.  The Form DWC-25 does not replace physician notes or other medical records.  The Form DWC-25 must be fully completed and must document the method(s) and guide used to assign a PI rating. Reimbursement will not be made for an evaluation and management code on the same date of service as a PI rating. Note: The procedure code for billing a PI rating is the CPT® code 99455. See the DFS-F5-DWC-25 Completion Instructions in Chapter 4.

2016 Edition

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Chapter 2 Medical Services, continued Psychiatric and Psychological Services 31B


Reimbursement for psychiatric and psychological services will be made by the carrier to the following recognized practitioners to provide individual psychotherapy services within the scope of state licensure:     

Medical doctors; Osteopathic physician; Psychologists; Mental health practitioners; Other qualified health professionals.

Required Documentation

All psychiatric and psychotherapy procedure codes that are reimbursed based on face-to-face time with the injured worker must have a beginning and an ending time documented in the medical record.

Individual Psychotherapy Combined with Evaluation and Management Codes

Only a physician may be reimbursed for individual psychotherapy in combination with evaluation and management services provided by a physician at a therapy session. Documentation must support the services billed. A physician will not be reimbursed for an evaluation and management procedure code (99201-99499) on the same day that reimbursement is made for psychotherapy combined with evaluation and management services. Note: Refer to the CPT® for specific psychiatric procedure codes to identify the combined codes.

Multiple Psychotherapy Sessions on the Same Day

2016 Edition

When more than one individual psychotherapy session is performed on the same day, only the session lasting the longest period of time will be reimbursed.

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Chapter 2 Medical Services, continued Psychiatric and Psychological Service, continued Family Psychotherapy

Reimbursement for family psychotherapy, with or without the injured worker present, will be made if the documentation supports that the purpose is related to the treatment of the injured worker’s compensable injury. Reimbursement will not be made for psychiatric or psychological services provided directly to members of the injured worker’s family for support and assistance in adjusting to the injured worker’s condition.

Central Nervous System Testing

Central Nervous System (CNS) Assessment and Testing must be specifically authorized by the carrier.

Reimbursement of CNS Testing

Reimbursement will be made for CNS Assessment and Testing. Reimbursement includes:   

An assessment and administration of a test with interpretation and a written report; The number of hours (units of service) reported by the provider to perform the assessment and testing; The procedure code used for billing indicating if the service is per hour or is all-inclusive.

Reimbursement will be the MRA in Chapter 3 of this Manual or the agreed upon contract price. Behavioral Assessment Interventions

Reimbursement will be made for Health and Behavior Assessment and Intervention Services when authorized by the carrier.

Billing

Providers must refer to the most specific Health and Behavior Assessment and Intervention procedure codes when billing for health and behavioral interventions.

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Chapter 2 Medical Services, continued Radiology 32B

Reimbursable Services

Reimbursement will be made for radiology services including diagnostic radiology (diagnostic imaging), diagnostic ultrasound and nuclear medicine.

Components of Radiology Reimbursement

Radiology services consist of two components: the technical component and the professional component. 



Technical Component: modifier TC When the technical component only [the actual performance of the radiological test and the production of film(s)] is reported separately, the service is billed by adding the HCPCS® modifier TC to the procedure code when requesting payment. Professional Component: modifier 26 When the professional component (physician interpretation of radiological test results) is reported separately, the service is billed by adding the HCPCS® modifier 26 to the procedure code when requesting payment.

Global Services

Global services may be reported when one practitioner provides both the technical and the professional components of a radiological procedure or service. The unmodified 5 digit procedure code is used to identify a global service inclusive of the professional service and the technical component of providing that service.

Reimbursement Policies

Reimbursement will not be made for a professional component (modifier 26) billed in the following situations:   

2016 Edition

A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed during an IME, CIME, medical visit or consultation. A professional component billed by a physician for reviewing x-rays during an emergency department or hospital visit when the x-rays were interpreted by the radiologist at the hospital. A professional component billed by a provider who is not the provider that reviewed, interpreted and signed the radiology report.

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Chapter 2 Medical Services, continued Radiology, continued Independent Radiology Facilities

Reimbursement will be made to an independent radiology facility for the technical component of the service by appending the modifier TC to the five (5) digit procedure code. No reimbursement will be made for the professional component of a service to an independent radiology facility. Only a technical component may be reimbursed to an independent radiology facility. The professional component will be billed separately by the health care provider that interprets the radiology exam.

Thermography 3B

Requirements for Authorization

The carrier will not authorize a physician to perform thermography any earlier than forty-five (45) calendar days after the date of accident unless the documentation of medical necessity is submitted to the carrier along with the request for authorization.

Thermography Limitations

Reimbursement for thermography is limited to one (1) body area; either major or limited. 1. Major body areas. (The following areas include all views.)  Head;  Cervical spine and upper extremities;  Lumbosacral spine and lower extremities. 2. Limited body areas. (The following areas include all views.)  Thoracic spine;  Any portion of a major area.

2016 Edition

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Chapter 2 Medical Services, continued Transcutaneous Electrical Neurostimulators (TENS) Reimbursement Requirements

An authorization and a written reimbursement agreement must be obtained from the carrier for rental or purchase of a TENS unit prior to a physician or other recognized practitioner furnishing a TENS unit to the injured worker. Reimbursement will shall be twenty percent (20%) above the provider’s documented cost when the TENS unit is purchased. A copy of the provider’s invoice must shall be submitted with the bill to substantiate the provider’s cost.

Training Sessions for TENS

Reimbursement will shall be made to an authorized physician or other recognized practitioner for furnishing training to an injured worker on the application and use of a TENS unit. Note: Reimbursement is limited to four (4) training sessions per approved TENS unit.

Physical Medicine and Rehabilitation Services 34B

General Information

Physical medicine and rehabilitation services will be considered as covered treatment only when such care is given based on a physician referral or prescription and when the medical necessity for such services is clearly supported in the recognized practitioner’s evaluation and in the specific physical medicine plan of care.

Covered Services

Carriers will reimburse authorized providers, as specified in this Manual, for the following physical medicine and rehabilitation services provided to injured workers for a compensable injury/illness: 1. Modalities and therapeutic procedures applied to acute injuries to reduce symptoms, restore function, and return the injured worker to work. 2. Physical reconditioning focused on injuries requiring intensive physical reconditioning services to restore the injured worker to pre-injury level of physical health and function. The goal will be for the worker to return to a job and/or become physically reconditioned. 3. Interdisciplinary rehabilitation programs covering a variety of services that are coordinated, outcome focused and directed at the injured worker’s needs to increase the worker’s functioning or to return the worker to work.

2016 Edition

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Chapter 2 Medical Services Physical Medicine and Rehabilitation Services, continued Authorization of Services

All services must be authorized in writing by the carrier prior to initiation of services. Reimbursement will only be made for physical medicine, therapeutic procedures, modalities and rehabilitation services up to six (6) months after the date of accident, based on a signed order or referral from an authorized, treating physician.

Exceptions to Limitations

Exceptions may be made to the above limitation when the treating provider provides documented, objective, relevant medical findings that demonstrate the following: 1. The injured worker has a specifically defined, relevant clinical dysfunction, consistent with the patient classifications outlined in Chapter 1 of this Manual, that is reasonably expected to respond to the requested physical medicine modalities or procedures; and 2. The injured worker does not conform to either the Level II or Level III patient classifications based on specific documentation of the following: a. No systemic musculoskeletal deficit (strength, flexibility, endurance, coordination) or substantive functional loss requiring an intensive physical reconditioning program; b. No behavioral or psychological issues that present a substantive factor in the rehabilitation effort or outcome; c. No significant vocational or return to work issues; and d. No significant disparity between the injured worker’s subjective complaints, response to intervention, and other relevant clinical indicators when compared with documented, objective, relevant findings. Note: See Classification of an Injured Worker Status in Chapter 1 of this Manual.

2016 Edition

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Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Physical Medicine Plan of Care (DWC-25)

The requirement of medically necessary physical medicine services (i.e., modalities and therapeutic services, physical reconditioning, or interdisciplinary rehabilitation programs) must be documented on the Form DWC-25 submitted to the carrier by the physician and supported in the evaluation with a specific physical medicine plan of care, regardless of the location of where the services are rendered or if rendered by a physician or other recognized practitioner.  

Service Limitations Physical Medicine Initial Evaluation by a Therapist

If the carrier questions the appropriateness of the therapy listed in the plan of care, the carrier must contact the physician to obtain the rationale for the ordered therapy, prior to authorization. It will be the responsibility of the physician to provide the documentation of medical necessity for the therapy to the carrier in order to avoid unnecessary delays in obtaining authorization for treatment or in initiating therapy.

Reimbursement for physical medicine services is limited to one visit per day, unless specifically authorized by the carrier.    

Reimbursement for an initial evaluation by a physician will be made as an evaluation and management service. Reimbursement for an initial evaluation by a therapist will be made when billed using procedure code 97001 or 97003. Separate reimbursement will not be made to a physician and to a physician-employed therapist for an evaluation by each on the same date of service. Reimbursement for an initial evaluation will include the evaluation and a plan of care or treatment.

Note: Documentation of the evaluation and preparation of a plan of care must be submitted to the carrier with the medical bill. At a minimum, the documentation must include: 1. The evaluation findings including any functional limitations; 2. The proposed therapy specifying the frequency and duration of services; and 3. The anticipated degree of restoration of function with measurable goals.

2016 Edition

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Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Evaluation by an Athletic Trainer

Re-Evaluation by an Athletic Trainer

a. Reimbursement for an initial evaluation, when performed by a physician, must be billed as an evaluation and management service. b. Reimbursement for an initial evaluation by an athletic trainer will be made only after a referral from a physician and billed using procedure code 97005. c. Separate reimbursement will not be made to a physician and to a physician-employed athletic trainer for an evaluation by each on the same date of service. d. Reimbursement for an initial evaluation by an athletic trainer must include the evaluation and a plan of care or treatment. Reimbursement will be made for a re-evaluation by an athletic trainer, when ordered by a physician, and documented on the DWC-25 no more than once every four (4) weeks. Re-evaluations must be billed using procedure code 97006.

Revised Plan of Care

2016 Edition

1. The physician must submit to the carrier a revised DWC-25 prepared by the physician to document the change in care or treatment, when appropriate. 2. An authorized treating physician CIME service must be billed with the Workers’ Compensation Unique code 99457 for reimbursement from the carrier. The physician performing the CIME has the responsibility for providing documentation of medical necessity for therapy modifications, if questioned by the carrier.

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Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Modalities and Therapeutic Procedures

Manipulative Treatment

Reimbursement to a physician or recognized practitioner will be made for the modalities and therapeutic procedures listed in the plan of care with the limitation that no more than four (4) units of service shall be reimbursed per visit. 

Codes 97010-97028 will each equal one (1) reimbursable unit of service. The performance of the supervised modality codes is not timeoriented and each code may only be reported once during the visit.



Codes 97032-97542 will each equal one (1) reimbursable unit of service for each fifteen (15) minute increment of service performed.



Code 97150 will be restricted to one (1) reimbursable unit of service per visit.

Reimbursement to a physician for a manipulative treatment will be limited to: 1. One (1) visit per day, 2. Two (2) body regions per visit. Each of the following is one body region: a. The entire spine; b. Head; c. Two (2) upper extremities; d. Two (2) lower extremities; e. One (1) upper and one (1) lower extremity; f. Rib cage; g. Abdomen.

Spinal Manipulation by a Physician

The entire spine shall be reimbursed as one (1) region for Workers’ Compensation even though there are five spinal (5) regions: a. Cervical; b. Thoracic; c. Lumbar; d. Sacral; and e. Pelvic. Reimbursement will be made to a physician for spinal manipulation when billed using procedure code 97260.

2016 Edition

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Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Manipulation of Extra-Spinal Regions

When manipulative treatment is performed by a physician on the: a. b. c. d. e. f.

Head region; Lower extremities; Upper extremities; One upper and one lower extremity; Rib cage and abdomen; and Viscera region.

Reimbursement will be made when the service is billed using procedure code 97261. Osteopathic Manipulative Treatment (OMT)

Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) body regions, spinal and extra-spinal, listed in this Chapter will be made for procedure codes 98926 and 98928, respectively. 



Chiropractic Manipulative Treatment (CMT)

Reimbursement will be made for code 98926 when used to bill for a spinal manipulation. The spine will be reimbursed as one (1) region for Workers’ Compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic). Reimbursement will be made for procedure code 98928 when used for manipulation to the head region; lower extremities; upper extremities; one upper and one lower extremity; rib cage and abdomen; and viscera region.

Reimbursement for CMT to two (2) regions, spinal and extra-spinal, listed in this section will be made when billed with procedure codes 98941 and 98943, respectively. These manipulation procedure codes are specifically designated for chiropractic physicians.

Chiropractic Spinal Manipulations

2016 Edition

Reimbursement will be made for procedure code 98941 when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) region for Workers’ Compensation, although there are five (5) spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costo-transverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region.

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Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Chiropractic Extra-Spinal Manipulations

Reimbursement will be made for procedure code 98943, when used to bill for a manipulation to an extra-spinal region: head (including temporomandibular joint, excluding atlanto-occipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.

Acupuncture 35B


Reimbursement for acupuncture will be made to a physician or a recognized practitioner specifically licensed by the Florida Department of Health to diagnose and treat with acupuncture.

Reimbursement Requirements

   

Limitations

Reimbursement for acupuncture or electro-acupuncture service is based on fifteen (15) minute increments of face-to-face contact with the patient during a session. Each treatment session consists of only one (1) initial fifteen minute (15 minute) increment. If additional time is required to be reported, use the appropriate add-on codes. Reinsertion of the acupuncture needle(s) is required for the use of acupuncture add-on codes.  

Reimbursement is limited to one visit per day. Only one (1) initial acupuncture treatment procedure code may be billed per injured worker per visit.

Note: A provider may not bill the initial acupuncture with electrical stimulation and without electrical stimulation for the same visit.

2016 Edition

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Chapter 2 Medical Services, continued Orthotics and Prosthetics 36B

Reimbursement Policies

All prosthetic or orthotic devices must be prescribed by the treating physician. Reimbursement will only be made to a licensed orthotics, prosthetics, occupational therapist, or physical therapist for custom fabricated orthotic or prosthetic device(s) when they directly provide the service. If the licensed provider is employed by a Home Medical Equipment supplier, a Home Health Agency, or any other employer, the bill is submitted by the employing party. When billing, orthotics and prosthetics must be billed using HCPCS® Level II codes that specifically describe the device.

Reimbursement

Prior written authorization by the carrier is a requirement for reimbursement of fabricated orthotics and prosthetics. Reimbursement for orthotics and prosthetics will be By Report (BR).

Orthotic Fitter and Orthotic Fitter Assistant

Orthotic Fitters and orthotic fitter assistants may be reimbursed for services provided within the scope of their licensure that are prescribed by a licensed treating health care provider. These services must be billed on the DWC-9 claim form using HCPCS® Level II codes that specifically describe the service or supply provided. The DOH license number of the orthotic fitter or orthotic fitter assistant must be on the claim form in Field 33b. If the licensed provider is employed by a Home Medical Equipment supplier, Home Health Agency, or any other employer the bill is submitted by the employing party.

2016 Edition

Page 52



Chapter 2 Medical Services, continued Tests and Measurements 37B

General Policies & Limitations

Reimbursement to a provider will be limited to one (1) visit by an injured worker per thirty (30) calendar days for tests and measurements to a selected body area or number of areas unless a different interval is outlined in the patient’s plan of care. A variation to the standard limitation for tests and measurements must be ordered by the treating physician and authorized by the carrier.

Billing

Providers must bill using the Workers’ Compensation unique code 97752, specifically designated for both the manual and automated testing.

Reimbursement

Reimbursement for tests and measurements must include a written report of the testing results. Manual muscle testing procedure codes and range of motion procedure codes will not be reimbursed when reported separately with procedure code 97752. Reimbursement will be made for range of motion measurements.

2016 Edition

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Chapter 2 Medical Services, continued Physical Reconditioning Services 38B


Reimbursement for physical reconditioning services will only be made to an authorized occupational therapist, physical therapist, or athletic trainer.

Authorization

Reimbursement will only be made for carrier authorized physical reconditioning based on a signed order from the authorized treating physician. Physical reconditioning services must be authorized by the carrier prior to initiation and must not begin any earlier than thirty (30) calendar days after the injured worker’s date of accident.

Physical Reconditioning Assessment

Reimbursement for a physical reconditioning assessment and written report will be determined from the number of hours reported by the provider to perform the assessment and the listed MRA. Note: Reimbursement is limited to eight (8) hours.   

2016 Edition

Reimbursement will be made for Workers’ Compensation Unique codes 97850 and 97851, specifically designated for use in reporting a physical conditioning assessment. Reimbursement will be made for procedure code 97850 only when it is used to bill for the initial hour of a physical reconditioning assessment. Reimbursement will be made for procedure code 97851 only for each additional thirty (30) minutes of a physical reconditioning assessment subsequent to procedure code 97850.

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Chapter 2 Medical Services, continued Physical Reconditioning Program 39B

General Reimbursement Guidelines

Reimbursement for a physical reconditioning program will be paid based on the number of hours billed by the provider and the listed MRA. Note: Reimbursement will be limited to a program lasting no longer than sixty (60) hours during a six (6) week period, which includes a physical reconditioning assessment.

Billing Guidelines

Reimbursement will be made for Workers’ Compensation Unique procedure codes 97852 and 97853, specifically designated for use in reporting a physical reconditioning program. 

Reimbursement will be made for procedure code 97852 to bill the initial per hour session of physical reconditioning each day.



Reimbursement will be made for procedure code 97853 when used to bill each additional thirty (30) minutes per session of physical reconditioning each day.

Multiple Therapies by the Same Provider

Reimbursement will be made for a physical reconditioning program when the services are provided alone, along with, or subsequent to modalities and procedures by the same authorized occupational therapist or physical therapist.

Limitations

Reimbursement will be made to a therapist or athletic trainer for only one (1) physical reconditioning program for an injured worker per date of accident, unless specifically authorized by the carrier for an exacerbation of the injury or surgical intervention, as documented by the treating physician. Note: Reimbursement for an extension of the program will be limited to reimbursement of an additional twenty (20) hours during a two (2) week period.

2016 Edition

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Chapter 2 Medical Services, continued 40B

Interdisciplinary Rehabilitation Programs Authorization

All services must be authorized prior to initiation of services. Reimbursement will only be made to a facility for carrier authorized interdisciplinary services based on a signed order from the authorized treating physician.

Exceptions to Policies

Approval beyond the policies provided in this section must be obtained from the carrier, in writing, prior to a health care provider furnishing the service. The unusual circumstances must be documented and forwarded by the health care provider to the carrier for review before an exception to the policies can be considered and a determination made by the carrier to authorize additional services.

CARF Accreditation Requirements

Reimbursement for Interdisciplinary Rehabilitation Programs will only be made to rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital. Rehabilitation Program services must be provided through a CARF accredited Outpatient Medical Rehabilitation Program, Occupational Rehabilitation Program or Interdisciplinary Pain Rehabilitation Program.

Work Hardening Programs

Reimbursement for a work hardening program will be made to a facility for the duration of the recommended individualized program. Procedure codes 97545 and 97546 are specifically designated to use exclusively in reporting the services of a work hardening program as follows:  

2016 Edition

Bill the initial two (2) hours of a work hardening program each day using procedure code 97545; Bill each additional hour of a work hardening program each day using procedure code 97546.

Page 56



Chapter 2 Medical Services, continued Interdisciplinary Rehabilitation Programs, continued Pain Programs

Reimbursement for an interdisciplinary pain management program will be made to a facility for the recommended time indicated in the injured worker’s program plan.

Pain Program Components

The services provided must relate to the physical, psychological, social, functional and vocational goals of the worker’s program plan. Services billed must reflect these components in the documentation submitted to the carrier for reimbursement.

Reimbursement for Pain Programs

Reimbursement will be made for biofeedback; physical and rehabilitation medicine services; pharmacy services; psychological and psychiatric services and testing; musculoskeletal services tests and measurements; neuromuscular services tests and studies, and other medically necessary services during the course of the program.

Discharge from an Interdisciplinary Program

The facility’s program director must determine if the injured worker will be discharged from the work hardening or pain program before completion. If the injured worker has not completed the program and program director recommends discontinuance of the program, the director will provide discharge information to the injured worker, the carrier and the treating physician without charge.

Discharge Report

Upon program completion, a report shall be sent by the facility’s program director without charge to the treating physician and to the carrier with the final bill. The report will include:  

Functional Capacity Evaluation (FCE)

The injured worker’s current clinical status and plan for transition from the program; and Return to work recommendations.

Reimbursement for an authorized FCE will be made at any time in the clinical continuum, as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s). Note: See Patient Classification System in Chapter 1 of this Manual

2016 Edition

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Chapter 2 Medical Services, continued Interdisciplinary Rehabilitation Programs, continued Requirements for FCE

All FCE protocols must be evidence-based. Test design and written interpretation must, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e. correlate impairment with disability). Note: Reimbursement will only be made when a physical therapist or occupational therapist is directly or actively involved with the testing protocol, although additional professional personnel may be involved as well.

Billing and Reimbursement for FCE

The provider must provide written results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge. The reimbursement for FCE includes a written program plan and a written report. Note: The Workers’ Compensation unique procedure code 97750 is designated for billing a FCE using the DFS-F5-DWC-9 Form.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services 41B

General Reimbursement Information

General reimbursement information from an authoritative resource is used to determine any limitations or reductions from the MRAs in Chapter 3. All procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and information are found in an authoritative resource, such as the National Physician Fee Schedule Relative Value File, copyrighted by the American Medical Association. The Relative Value File is available from the American Medical Association, 515 N. State Street, Chicago, IL 60610 or by calling 1800-621-8335. These indicators will be used to determine reimbursement by the Division.

Global Surgical Package

Reimbursement for a surgical package (global reimbursement) will include the provision of certain services before and after surgery. Payment for these services will include:        

The immediate preoperative visit; Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia; The surgical procedure; Immediate postoperative care, including dictating operative notes, talking with the family and other physicians; Writing orders; Evaluating the patient in the post-anesthesia recovery area; Typical postoperative follow-up care; and The time period for routine follow-up care related to the surgical procedure is listed in the Follow-Up Days (FUD) column in Chapter 3, Part B. 1. Reimbursement for a procedure code with a ZZZ designation for the global period will be the same as the other procedure code that is billed in conjunction with this “add-on” procedure code. 2. Reimbursement for a procedure code with a YYY designation in the global period will be set by the carrier.

Note: The maximum reimbursement allowance (MRA) to physicians for surgical procedures will be found in Chapter 3, Part B of this Manual.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services, continued Services Reimbursed in Addition to Global Package

Reimbursement will be made for other services in addition to the surgical package only in the following situations when: 

  

Surgery Performed During Post-Op Period

The preoperative visit is the initial visit made by the provider, when prolonged detention or evaluation is necessary to prepare an injured worker for surgery and when there is a need to establish the reason for a particular type of surgery; The preoperative visit is a consultation; The preoperative services are not part of the usual preparation for the particular surgical procedure; and The services are to treat complications, exacerbations, recurrences or other diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered must be submitted with the medical bill.

Reimbursement for surgical services will be made when an additional surgery is performed during the postoperative period of another surgical procedure. Reimbursement for normal postoperative care must run concurrently and must be made according to the separate FUD periods listed in Chapter 3, Part B unless it is a procedure code with the YYY designation. For theses codes, the FUD period will be set by the carrier.

Assistant Surgeon

2016 Edition

Reimbursement for an assistant surgeon will be twenty-five percent (25%) of the physician reimbursement listed in the MRAs in Chapter 3, Part B of this Manual. The services provided must be identified by appending the modifier 80 to the specific procedure code.

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Chapter 2 Medical Services, continued Surgical Services, continued Non-Physician Surgical Assistants

Reimbursement will be made to a non-physician surgical assistant for surgical services. Non-physician surgical assistants include: physician assistants, advanced registered nurse practitioners and registered nurse first assistants.

Billing Requirements for Non-Physician Surgical Assistants

The surgical procedure code(s) must be appended with the HCPCS® Level II modifier AS to identify services rendered by a non-physician surgical assistant at surgery. Non-physician surgical assistants must follow the billing requirements in Rule Chapter 69L-7, F.A.C. The non-physician surgical assistant must provide his or her Florida DOH license number in Field 33b on the DWC-9 medical bill form. Note: No reimbursement is made to non-physician surgical assistants employed by hospitals.

Reimbursement for Non-Physician Surgical Assistants

Reimbursement will be made for non-physician surgical assistants performing surgical services. Reimbursement will be seventy-five percent (75%) of twentyfive percent (25%) of the MRA listed in Chapter 3, Part B when the carrier has determined:   

The non-physician meets state licensure requirements and Written authorization to the non-physician surgical assistant was provided by the carrier prior to the surgery or, During a medical emergency, a physician was not available to assist at surgery.

Procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and other information shall be utilized for determining reimbursement for all claims. These indicators will come from an authoritative resource, such as the National Physician Fee Schedule Relative Value File, copyrighted by the American Medical Association. The Relative Value File is available from the American Medical Association, 515 N. State Street, Chicago, IL 60610 or by calling 1-800-621-8335. These indicators will be used to determine reimbursement by the Division.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services, continued Two Surgeons Distinct Parts

Reimbursements will be made to two (2) surgeons at the same operative session for performing distinct parts of a surgical procedure. The services provided must be identified by the same procedure code with modifier 62 appended.

Two Surgeons Separate Procedures

Reimbursement will be made to two surgeons for rendering separate surgical procedures during the same operative session. The services must be identified by billing different, unmodified procedure codes. Reimbursement to each surgeon will be:  

The listed MRA in Chapter 3; Part B; or The agreed upon contract price.

Note: Reimbursement will not be made to either surgeon until the carrier has received and reviewed each surgeon’s bill and individual operative reports. Surgical Team

Reimbursement for a surgical team will be made By Report (BR) to each team member for each surgeon’s surgical service. Each team member must identify the specific procedure they provided by appending modifier 66 to the procedure code(s) billed. Note: Reimbursement will not be made until all surgical bills and individual operative reports are received and reviewed by the carrier.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services, continued Reimbursement will be made for all medically necessary surgical procedures when Billing and more than one (1) procedure is performed at a single operative session. Reimbursement for Multiple Surgical  Each procedure performed must be identified by use of the appropriate Procedures five-digit CPT® code and listed separately.  The primary, or most significant procedure, must be reported first.  Each additional procedure code must be listed separately and reported with a modifier 51. Reimbursement for the primary surgical procedure will be the MRA listed in Chapter 3, Part B of this Manual or the agreed upon contract price. Reimbursement for additional surgical procedure(s) will be fifty percent (50%) of the listed MRA in Chapter 3, Part B of this Manual or the agreed upon contract price. Note: Designated add-on procedure codes, listed in the CPT® Manual are exempt from modifier 51 billing and the multiple surgery pricing reduction rules. Add-on procedure codes must not be billed with a modifier 51. Add-on procedure codes must be billed immediately following their primary procedure codes for proper identification and reimbursement. Note: If there is an agreed upon contract between the health care provider and the carrier, the contract establishes the reimbursement at a specified contract price. Billing and Reimbursement for Procedures Listed as Bilateral

Bilateral procedures that are listed as “bilateral” in the CPT® description are exempt from modifier 50. Bill using the five digit procedure code only. Reimbursement will be:  The MRA listed in Chapter 3, Part B in this Manual; or  The agreed upon contract price.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services, continued Billing and Reimbursement for Bilateral Procedures Not Listed as Bilateral

Procedures performed bilaterally that do not contain the word “bilateral” in CPT® require a modifier to identify they are performed bilaterally for proper reimbursement. Bill the five digit procedure code on one line only using modifier 50. Reimbursement for a bilateral procedure that does not include the word “bilateral” in the description will only be made when the payment policy indicators from an authoritative resource, such as the National Physician Fee Schedule Relative Value File, allows bilateral reimbursement. If the payment policy indicator allows bilateral reimbursement, the maximum reimbursement amount will be:  

2016 Edition

One hundred and fifty percent (150%) of the MRA, unless otherwise stated in this Manual; or The agreed upon contract price.

Page 64



Chapter 2 Medical Services, continued Surgical Services, continued Bilateral Procedures with Multiple Surgery

  

Bill the first procedure code on the first line without modifier 51; Bill additional procedure(s) using modifier 51 to indicate multiple procedures performed during the same operative session; and For the bilateral procedure(s), use modifier 50 in the first modifier position followed by modifier 51 in the second modifier position, where appropriate.

Note: Add-on procedure codes, listed in the CPT® Manual, are exempt from modifier 51 billing and from the multiple surgery pricing reduction rules. Add-on procedure codes must not be billed with a modifier 51. Bilateral Procedures Performed Unilaterally Procedures

When a procedure is listed in the CPT® as a bilateral-procedure, but, it is performed only unilaterally, the procedure must be identified with a modifier 52. Reimbursement will be fifty percent (50%) of:  The MRA listed in Chapter 3, Part B; or  The agreed upon contract amount for a bilateral procedure.

Terminated Procedures

A bill submitted for reimbursement of a terminated surgery must include documentation that specifies the following: 1. Reason for termination of surgery; 2. Services, reported by CPT® code, that were actually performed; 3. Services, reported by CPT® code, not performed that would have been performed if surgery had not been terminated; 4. Supplies actually provided; 5. Supplies not provided that would have been provided if the surgery had not been terminated; 6. Time actually spent by the health care provider in each stage, e.g. pre-operative, operative, and post-operative; 7. Time that would have been spent in each of these stages if the surgery had not been terminated; and 8. Modifier 53 must be added to the procedure codes to identify the circumstances under which the services were terminated.

2016 Edition

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Chapter 2 Medical Services, continued Surgical Services, continued Reimbursement for Terminated Procedures

Terminated Procedures will be reimbursed as follows:  



Modifier 51 Exempt

No reimbursement will be made for a procedure that is terminated either for medical or non-medical reasons before the pre-operative procedures are initiated by staff. Reimbursement will be fifty percent (50%) of the amount allowed for the procedure(s), according to the policies in this Manual, if a procedure is terminated due to the onset of medical complications after the patient has been taken to the operating suite, but before anesthesia has been induced. Payment will be fifty percent (50%) of the amount allowed for the procedure(s), according to policies in this Manual, if a medical complication arises which causes the procedure to be terminated after induction of anesthesia.

A procedure code that is “Modifier 51 Exempt” is a HCPCS or CPT® code typically performed with another procedure. These procedure codes are summarized, but not completely identified, in the CPT codebook incorporated by reference in Rule 69L-8.074, F.A.C. “Modifier 51 Exempt” procedure codes do not require modifier 51 in Field 24d on DFS-F5-DWC-9 Claim Form and are reimbursed at 100% of the Maximum Reimbursement Allowance (MRA).

2016 Edition

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2016 Edition

Page 67



Chapter 3 Maximum Reimbursement Allowances 2B

General Instructions

This chapter establishes the Maximum Reimbursement Allowances (MRAs) for services and procedures performed by workers’ compensation providers of this manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement.

Part A

Part A establishes the Maximum Reimbursement Allowances (MRAs) for services and procedures performed by workers’ compensation providers not specifically addressed in this Manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement. Part A also includes the basic value (or base unit) on which reimbursement will be calculated for all anesthesia services according to this Manual.

Part B

Part B establishes the Maximum Reimbursement Allowances (MRAs) for Florida physician providers of surgical procedures and services. Physician assistants and advanced registered nurse practitioners will be paid eightyfive percent (85%) of the physician’s MRA when these non-physician providers directly perform the surgical procedure or service.

Part C

Part C establishes the Maximum Reimbursement Allowances (MRAs) for Florida physicians, physical and occupational therapists, athletic trainers, audiologists, speech pathologists, and psychologist providers of non-surgical procedures and services. Physician assistants and advanced registered nurse practitioners will be paid eighty-five percent (85%) of the physician’s MRA when these non-physician providers directly perform a non-surgical procedure or service. Part C also establishes the MRAs for independent clinical laboratories, freestanding imaging/x-ray centers, dietitians, nutritionists, nutrition counselors and clinical social workers.

2016 Edition

Page 68



Chapter 3 Maximum Reimbursement Allowances, continued To determine the MRA to which a provider is entitled under Part B or Part C: Determining the MRA

A. Determine the county location of the provider according to the Medicare locality map in Appendix C. B. Determine whether the procedure should be paid according to the nonfacility MRA (services rendered in a provider’s office, urgent care center, diagnostic facility, nursing home, home health agency or home) or the facility MRA (services rendered in a hospital setting, ambulatory surgical center, skilled nursing facility, inpatient psychiatric facility, or comprehensive [Level III] outpatient rehabilitation facility). C. Identify the specific CPT® code in the far left column of the matrix and the correct locality/non-facility or facility column across the top row. D. Locate the point of intersection for the procedure code row and the appropriate non-facility or facility locality column on the reimbursement matrix. E. Compare the amount allowed at the point of intersection on the matrix to the amount listed in the 2003 column. F. Reimburse the provider the greater of the amount in the 2003 MRA column or the amount in the column at the point of intersection.

2016 Edition

Page 69


Chapter 3 Maximum Reimbursement Allowances, continued

PART A SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES

2016 Edition

Page 70


Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2016 Edition RULE- 69L-7.020, F.A.C., Effective July 1, 2017

Anesthesia CPT Code 00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00211 00212 00214 00215 00216 00218 00220 00222 00300 00320 00322 00350 00352 00400 00402 00404 00406 00410 00450 00454 00470 00472 00474 00500 00520 00522 00524

BV + TM 5 + TM 6 + TM 5 + TM 4 + TM 5 + TM 4 + TM 4 + TM 5 + TM 4 + TM 6 + TM 6 + TM 6 + TM 4 + TM 5 + TM 7 + TM 4 + TM 5 + TM 6 + TM 6 + TM 7 + TM 5 + TM 7 + TM 11 + TM 10 + TM 5 + TM 9 + TM 9 + TM 15 + TM 13 + TM 10 + TM 6 + TM 5 + TM 6 + TM 3 + TM 10 + TM 5 + TM 3 + TM 5 + TM 5 + TM 13 + TM 4 + TM 5 + TM 3 + TM 6 + TM 10 + TM 13 + TM 15 + TM 6 + TM 4 + TM 4 + TM



CPT only © 2015 American Medical Association. All Rights Reserved.



PartA, 71







Anesthesia CPT Code 01951 01952 01953 01960 01961 01962 01963 01967 01968 01969 01990 01991 01992 01996 01999

BV + TM 3 + TM 5 + TM 1 + TM 5 + TM 7 + TM 8 + TM 10 + TM 5 + TM 3 + TM 5 + TM 0 3 + TM 5 + TM 3 BR

PartA, 72


Surgery CPT Code 10021 10022 10030 10035 10036 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11004 11005 11006 11008 11010 11011 11012 11042 11043 11044 11045 11046 11047 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400

MRA $90.00 $92.00 $791.00 $544.00 $473.00 $54.00 $53.00 $133.00 $65.00 $203.00 $53.00 $169.00 $53.00 $45.00 $164.00 $45.00 $27.00 $564.00 $768.00 $710.00 $289.00 $348.00 $432.00 $597.00 $88.00 $210.00 $283.00 $43.00 $75.00 $127.00 $26.00 $35.00 $39.00 $78.00 $41.00 $66.00 $26.00 $59.00 $80.00 $96.00 $119.00 $61.00 $86.00 $100.00 $125.00 $75.00 $95.00 $110.00 $144.00 $81.00

FUD 0 0 0 0 ZZZ 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 0 0 ZZZ 10 0 0 0 0 0 ZZZ ZZZ ZZZ 0 0 0 0 ZZZ 10 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 10

Surgery CPT Code 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755

MRA $114.00 $145.00 $178.00 $200.00 $246.00 $98.00 $92.00 $157.00 $163.00 $221.00 $303.00 $105.00 $102.00 $174.00 $221.00 $276.00 $344.00 $282.00 $366.00 $264.00 $351.00 $320.00 $391.00 $148.00 $180.00 $199.00 $226.00 $249.00 $315.00 $150.00 $191.00 $223.00 $259.00 $305.00 $373.00 $168.00 $227.00 $260.00 $305.00 $380.00 $494.00 $22.00 $32.00 $50.00 $62.00 $31.00 $41.00 $156.00 $234.00 $106.00

FUD 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 0 0 0 ZZZ 0 10 10 0


Surgery CPT Code 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054

MRA $131.00 $223.00 $65.00 $275.00 $496.00 $585.00 $33.00 $37.00 $147.00 $172.00 $40.00 $107.00 $114.00 $155.00 $165.00 $829.00 $632.00 $280.00 $123.00 $84.00 $98.00 $122.00 $165.00 $203.00 $339.00 $98.00 $141.00 $165.00 $207.00 $268.00 $316.00 $515.00 $211.00 $87.00 $93.00 $110.00 $148.00 $223.00 $356.00 $411.00 $116.00 $141.00 $176.00 $250.00 $341.00 $363.00 $126.00 $148.00 $223.00 $301.00

FUD 10 10 10 10 90 90 0 0 0 0 ZZZ 0 0 0 0 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

Part A, 73


Surgery CPT Code MRA 12055 $380.00 12056 $487.00 12057 $539.00 13100 $178.00 13101 $240.00 13102 $89.00 13120 $223.00 13121 $348.00 13122 $104.00 13131 $252.00 13132 $484.00 13133 $154.00 13151 $375.00 13152 $542.00 13153 $169.00 13160 $655.00 14000 $512.00 14001 $695.00 14020 $590.00 14021 $818.00 14040 $701.00 14041 $936.00 14060 $766.00 14061 $1,330.00 14301 $1,088.00 14302 $228.00 14350 $734.00 15002 $351.00 15003 $77.00 15004 $407.00 15005 $127.00 15040 $258.00 15050 $349.00 15100 $679.00 15101 $146.00 15110 $815.00 15111 $129.00 15115 $766.00 15116 $167.00 15120 $788.00 15121 $235.00 15130 $677.00 15131 $105.00 15135 $820.00 15136 $98.00 15150 $677.00 15151 $136.00 15152 $167.00 15155 $678.00 15156 $177.00

FUD 10 10 10 10 10 ZZZ 10 10 ZZZ 10 10 ZZZ 10 10 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ 90 0 ZZZ 0 ZZZ 0 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ ZZZ 90 ZZZ

Surgery CPT Code 15157 15200 15201 15220 15221 15240 15241 15260 15261 15271 15272 15273 15274 15275 15276 15277 15278 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740 15750 15756 15757 15758 15760 15770 15775 15776 15777 15780 15781 15782 15783 15786 15787 15788 15789 15792

MRA $196.00 $644.00 $126.00 $687.00 $114.00 $763.00 $334.00 $841.00 $207.00 $143.00 $27.00 $299.00 $70.00 $155.00 $35.00 $320.00 $83.00 $748.00 $721.00 $775.00 $457.00 $259.00 $320.00 $506.00 $362.00 $427.00 $990.00 $1,465.00 $1,557.00 $1,862.00 $1,415.00 $913.00 $1,064.00 $2,892.00 $2,892.00 $2,884.00 $810.00 $674.00 $327.00 $475.00 $219.00 $532.00 $420.00 $314.00 $340.00 $146.00 $27.00 $194.00 $360.00 $130.00

FUD ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 ZZZ 90 90 90 90 10 ZZZ 90 90 90


Surgery CPT Code 15793 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15830 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15850 15851 15852 15860 15876 15877 15878 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 15946 15950 15951 15952 15953 15956

MRA $232.00 $780.00 $556.00 $607.00 $499.00 $718.00 BR BR BR BR BR $1,072.00 $926.00 $833.00 $837.00 $865.00 $721.00 $696.00 $600.00 $643.00 $1,187.00 $1,859.00 $3,099.00 $1,116.00 $63.00 $40.00 $35.00 $151.00 BR BR BR BR $571.00 $771.00 $638.00 $860.00 $1,064.00 $1,184.00 $1,032.00 $1,223.00 $318.00 $919.00 $954.00 $1,078.00 $1,737.00 $549.00 $872.00 $876.00 $1,013.00 $1,382.00

FUD 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 74


Surgery CPT Code MRA 15958 $1,379.00 15999 BR 16000 $53.00 16020 $49.00 16025 $67.00 16030 $153.00 16035 $341.00 16036 $81.00 17000 $60.00 17003 $16.00 17004 $233.00 17106 $341.00 17107 $648.00 17108 $1,015.00 17110 $55.00 17111 $83.00 17250 $27.00 17260 $96.00 17261 $117.00 17262 $150.00 17263 $172.00 17264 $189.00 17266 $225.00 17270 $125.00 17271 $143.00 17272 $170.00 17273 $195.00 17274 $240.00 17276 $281.00 17280 $123.00 17281 $165.00 17282 $194.00 17283 $239.00 17284 $282.00 17286 $373.00 17311 $629.00 17312 $380.00 17313 $575.00 17314 $352.00 17315 $74.00 17340 $37.00 17360 $96.00 17380 BR 17999 BR 19000 $74.00 19001 $40.00 19020 $288.00 19030 $98.00 19081 $682.00 19082 $551.00

FUD 90 YYY 0 0 0 0 0 ZZZ 10 ZZZ 10 90 90 90 10 10 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 ZZZ ZZZ 10 10 0 YYY 0 ZZZ 90 0 0 ZZZ

Surgery CPT Code 19083 19084 19085 19086 19100 19101 19105 19110 19112 19120 19125 19126 19260 19271 19272 19281 19282 19283 19284 19285 19286 19287 19288 19296 19297 19298 19300 19301 19302 19303 19304 19305 19306 19307 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368

MRA $677.00 $543.00 $1,025.00 $817.00 $117.00 $338.00 $1,878.00 $406.00 $354.00 $429.00 $468.00 $201.00 $1,101.00 $1,561.00 $1,674.00 $246.00 $171.00 $279.00 $205.00 $472.00 $396.00 $875.00 $696.00 $4,903.00 $96.00 $1,841.00 $482.00 $367.00 $780.00 $788.00 $487.00 $964.00 $1,003.00 $1,008.00 $954.00 $1,313.00 $440.00 $656.00 $457.00 $569.00 $545.00 $963.00 $853.00 $755.00 $1,449.00 $1,667.00 $2,737.00 $1,676.00 $2,056.00 $2,444.00

FUD 0 ZZZ 0 ZZZ 0 10 0 90 90 90 90 ZZZ 90 90 90 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code MRA 19369 $2,317.00 19370 $662.00 19371 $788.00 19380 $780.00 19396 $231.00 19499 BR 20005 $267.00 20100 $727.00 20101 $261.00 20102 $314.00 20103 $405.00 20150 $1,141.00 20200 $134.00 20205 $243.00 20206 $119.00 20220 $128.00 20225 $215.00 20240 $279.00 20245 $364.00 20250 $447.00 20251 $511.00 20500 $59.00 20501 $60.00 20520 $75.00 20525 $331.00 20526 $64.00 20527 $84.00 20550 $40.00 20551 $62.00 20552 $62.00 20553 $62.00 20555 $301.00 20600 $41.00 20604 $73.00 20605 $48.00 20606 $81.00 20610 $49.00 20611 $93.00 20612 $56.00 20615 $94.00 20650 $170.00 20660 $320.00 20661 $476.00 20662 $559.00 20663 $465.00 20665 $105.00 20670 $80.00 20680 $332.00 20690 $298.00 20692 $516.00

FUD 90 90 90 90 0 YYY 10 10 10 10 10 90 0 0 0 0 0 0 10 10 10 10 0 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 10 0 90 90 90 10 10 90 90 90

Part A, 75


Surgery CPT Code 20693 20694 20696 20697 20802 20805 20808 20816 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924 20926 20930 20931 20936 20937 20938 20950 20955 20956 20957 20962 20969 20970 20972 20973 20974 20975 20979 20982 20983 20985 20999 21010 21011 21012 21013 21014 21015 21016 21025 21026

MRA $477.00 $421.00 $1,156.00 $1,860.00 $3,363.00 $4,317.00 $5,324.00 $3,060.00 $2,511.00 $3,027.00 $3,920.00 $3,484.00 $454.00 $658.00 $338.00 $549.00 $460.00 $634.00 $583.00 $444.00 BR $156.00 BR $234.00 $257.00 $123.00 $3,332.00 $3,167.00 $3,074.00 $3,122.00 $3,716.00 $3,650.00 $3,420.00 $3,821.00 $266.00 $334.00 $19.00 $4,231.00 $7,394.00 $140.00 BR $854.00 $349.00 $341.00 $521.00 $528.00 $520.00 $1,063.00 $546.00 $413.00

FUD 90 90 90 0 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 0 ZZZ 0 ZZZ ZZZ 0 90 90 90 90 90 90 90 90 0 0 0 0 0 ZZZ YYY 90 90 90 90 90 90 90 90 90

Surgery CPT Code 21029 21030 21031 21032 21034 21040 21044 21045 21046 21047 21048 21049 21050 21060 21070 21073 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154

MRA $700.00 $496.00 $310.00 $315.00 $1,140.00 $227.00 $957.00 $1,313.00 $899.00 $1,109.00 $925.00 $1,051.00 $1,026.00 $972.00 $679.00 $337.00 $1,192.00 $3,002.00 $2,086.00 $2,346.00 $2,138.00 $1,855.00 $1,802.00 $2,105.00 $801.00 $2,333.00 $2,217.00 BR BR $297.00 $371.00 $207.00 $500.00 $651.00 $700.00 $903.00 $656.00 $909.00 $797.00 $960.00 $1,168.00 $1,438.00 $1,527.00 $1,511.00 $1,513.00 $1,570.00 $1,639.00 $1,914.00 $2,264.00 $2,364.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 10 90 90 90 YYY 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 21155 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21188 21193 21194 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296 21299 21310 21315

MRA $2,640.00 $3,302.00 $3,500.00 $2,111.00 $2,604.00 $1,826.00 $2,035.00 $813.00 $2,570.00 $2,770.00 $3,150.00 $1,786.00 $1,331.00 $1,540.00 $1,360.00 $1,764.00 $1,268.00 $1,018.00 $1,112.00 $946.00 $576.00 $930.00 $970.00 $956.00 $707.00 $1,281.00 $1,207.00 $1,501.00 $1,062.00 $1,038.00 $1,010.00 $2,003.00 $1,023.00 $1,525.00 $1,459.00 $1,470.00 $1,372.00 $2,347.00 $2,361.00 $1,539.00 $1,946.00 $890.00 $963.00 $571.00 $360.00 $144.00 $384.00 BR $81.00 $180.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 10

Part A, 76


Surgery CPT Code 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 21348 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480

MRA $235.00 $348.00 $639.00 $852.00 $478.00 $300.00 $550.00 $689.00 $907.00 $1,043.00 $1,450.00 $738.00 $917.00 $1,048.00 $1,286.00 $295.00 $372.00 $590.00 $1,239.00 $1,386.00 $810.00 $812.00 $958.00 $920.00 $1,384.00 $143.00 $313.00 $852.00 $736.00 $1,007.00 $528.00 $761.00 $890.00 $598.00 $744.00 $1,981.00 $1,404.00 $2,045.00 $308.00 $533.00 $325.00 $498.00 $195.00 $902.00 $905.00 $769.00 $1,012.00 $923.00 $1,331.00 $82.00

FUD 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0

Surgery CPT Code 21485 21490 21495 21497 21499 21501 21502 21510 21550 21552 21554 21555 21556 21557 21558 21600 21610 21615 21616 21620 21627 21630 21632 21685 21700 21705 21720 21725 21740 21742 21743 21750 21811 21812 21813 21820 21825 21899 21920 21925 21930 21931 21932 21933 21935 21936 22010 22015 22100 22101

MRA $318.00 $865.00 $500.00 $372.00 BR $315.00 $612.00 $534.00 $165.00 $453.00 $744.00 $337.00 $431.00 $794.00 $1,380.00 $631.00 $828.00 $938.00 $1,042.00 $689.00 $686.00 $1,455.00 $1,514.00 $918.00 $576.00 $746.00 $523.00 $588.00 $1,387.00 BR BR $1,009.00 $634.00 $761.00 $992.00 $143.00 $810.00 BR $165.00 $371.00 $403.00 $478.00 $672.00 $749.00 $1,280.00 $1,442.00 $822.00 $815.00 $850.00 $862.00

FUD 90 90 90 90 YYY 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 90 YYY 10 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 22102 22103 22110 22112 22114 22116 22206 22207 22208 22210 22212 22214 22216 22220 22222 22224 22226 22305 22310 22315 22318 22319 22325 22326 22327 22328 22505 22510 22511 22512 22513 22514 22515 22526 22527 22532 22533 22534 22548 22551 22552 22554 22556 22558 22585 22586 22590 22595 22600 22610

MRA $781.00 $198.00 $889.00 $1,090.00 $1,062.00 $195.00 $2,153.00 $2,126.00 $545.00 $1,892.00 $1,668.00 $819.00 $492.00 $1,801.00 $1,604.00 $1,731.00 $488.00 $213.00 $272.00 $711.00 $1,755.00 $1,983.00 $1,407.00 $1,710.00 $1,660.00 $391.00 $174.00 $1,804.00 $1,786.00 $1,001.00 $7,471.00 $7,462.00 $4,518.00 $2,013.00 $1,637.00 $1,618.00 $1,509.00 $381.00 $2,271.00 $1,759.00 $406.00 $1,727.00 $2,054.00 $1,907.00 $473.00 $1,926.00 $1,895.00 $1,960.00 $1,567.00 $1,494.00

FUD 90 ZZZ 90 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 10 10 10 ZZZ 10 10 ZZZ 10 ZZZ 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90

Part A, 77


Surgery CPT Code 22612 22614 22630 22632 22633 22634 22800 22802 22804 22808 22810 22812 22818 22819 22830 22840 22841 22842 22843 22844 22845 22846 22847 22848 22849 22850 22851 22852 22855 22856 22857 22858 22861 22862 22864 22865 22899 22900 22901 22902 22903 22904 22905 22999 23000 23020 23030 23031 23035 23040

MRA $1,861.00 $530.00 $1,201.00 $442.00 $1,894.00 $511.00 $1,960.00 $2,633.00 $2,951.00 $2,157.00 $2,356.00 $2,675.00 $2,701.00 $2,968.00 $1,176.00 $943.00 BR $2,352.00 $1,028.00 $1,277.00 $1,853.00 $999.00 $1,077.00 $529.00 $2,235.00 $872.00 $600.00 $854.00 $1,193.00 $1,701.00 $1,386.00 $527.00 $2,262.00 $1,690.00 $2,035.00 $1,646.00 BR $446.00 $673.00 $436.00 $440.00 $1,069.00 $1,362.00 BR $447.00 $807.00 $323.00 $185.00 $861.00 $898.00

FUD 90 ZZZ 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 ZZZ 0 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 YYY 90 90 90 90 90 90 YYY 90 90 10 10 90 90

Surgery CPT Code 23044 23065 23066 23071 23073 23075 23076 23077 23078 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195 23200 23210 23220 23330 23333 23334 23335 23350 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440

MRA $708.00 $171.00 $302.00 $426.00 $705.00 $247.00 $613.00 $1,228.00 $1,476.00 $616.00 $583.00 $814.00 $581.00 $851.00 $645.00 $865.00 $722.00 $597.00 $889.00 $704.00 $755.00 $945.00 $794.00 $645.00 $638.00 $882.00 $566.00 $865.00 $962.00 $656.00 $902.00 $1,095.00 $1,095.00 $1,307.00 $59.00 $466.00 $1,100.00 $1,312.00 $74.00 $1,366.00 $1,403.00 $1,196.00 $799.00 $977.00 $1,119.00 $1,229.00 $622.00 $1,276.00 $884.00 $906.00

FUD 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 23450 23455 23460 23462 23465 23466 23470 23472 23473 23474 23480 23485 23490 23491 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 23670 23675 23680 23700 23800 23802 23900 23920 23921 23929 23930

MRA $1,210.00 $1,340.00 $1,364.00 $1,383.00 $1,398.00 $1,332.00 $1,540.00 $1,570.00 $1,672.00 $1,807.00 $926.00 $1,181.00 $1,038.00 $1,251.00 $148.00 $293.00 $688.00 $205.00 $320.00 $659.00 $713.00 $148.00 $148.00 $701.00 $753.00 $88.00 $306.00 $809.00 $318.00 $511.00 $900.00 $1,895.00 $286.00 $422.00 $712.00 $296.00 $374.00 $712.00 $440.00 $759.00 $550.00 $1,064.00 $237.00 $1,346.00 $1,368.00 $1,561.00 $1,300.00 $497.00 BR $71.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 YYY 10

Part A, 78


Surgery CPT Code 23931 23935 24000 24006 24065 24066 24071 24073 24075 24076 24077 24079 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24152 24155 24160 24164 24200 24201 24220 24300 24301 24305 24310 24320 24330 24331 24332 24340 24341 24342 24343

MRA $62.00 $630.00 $550.00 $793.00 $166.00 $461.00 $413.00 $704.00 $349.00 $529.00 $1,058.00 $1,357.00 $467.00 $591.00 $755.00 $360.00 $724.00 $898.00 $1,037.00 $595.00 $663.00 $731.00 $595.00 $966.00 $720.00 $697.00 $963.00 $592.00 $703.00 $1,224.00 $1,265.00 $829.00 $1,019.00 $533.00 $564.00 $58.00 $444.00 $89.00 $352.00 $869.00 $579.00 $511.00 $944.00 $845.00 $927.00 $487.00 $697.00 $702.00 $950.00 $643.00

FUD 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 24344 24345 24346 24357 24358 24359 24360 24361 24362 24363 24365 24366 24370 24371 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 24605 24615 24620 24635 24650 24655 24665 24666

MRA $971.00 $643.00 $971.00 $408.00 $478.00 $587.00 $1,125.00 $1,215.00 $1,269.00 $1,663.00 $747.00 $850.00 $1,581.00 $1,826.00 $991.00 $1,319.00 $1,265.00 $1,209.00 $1,260.00 $774.00 $742.00 $1,076.00 $288.00 $574.00 $1,018.00 $1,029.00 $88.00 $671.00 $850.00 $946.00 $1,273.00 $266.00 $526.00 $705.00 $872.00 $295.00 $575.00 $964.00 $773.00 $1,314.00 $1,278.00 $360.00 $371.00 $836.00 $560.00 $1,329.00 $262.00 $436.00 $749.00 $905.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 24670 24675 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 24999 25000 25001 25020 25023 25024 25025 25028 25031 25035 25040 25065 25066 25071 25073 25075 25076 25077 25078 25085 25100 25101 25105 25107 25109 25110 25111 25112 25115 25116 25118 25119 25120 25125 25126 25130 25135 25136

MRA $263.00 $490.00 $819.00 $984.00 $1,181.00 $858.00 $851.00 $661.00 $928.00 $1,063.00 $1,327.00 BR BR $381.00 $294.00 $594.00 $1,040.00 $683.00 $1,104.00 $417.00 $266.00 $794.00 $654.00 $164.00 $322.00 $432.00 $540.00 $352.00 $544.00 $957.00 $1,195.00 $562.00 $420.00 $492.00 $635.00 $600.00 $470.00 $403.00 $356.00 $441.00 $837.00 $807.00 $466.00 $653.00 $712.00 $803.00 $781.00 $502.00 $631.00 $546.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 79


Surgery CPT Code 25145 25150 25151 25170 25210 25215 25230 25240 25246 25248 25250 25251 25259 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301 25310 25312 25315 25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 25405 25415 25420 25425 25426

MRA $713.00 $720.00 $771.00 $1,085.00 $561.00 $817.00 $531.00 $567.00 $72.00 $236.00 $616.00 $933.00 $348.00 $728.00 $809.00 $998.00 $549.00 $613.00 $887.00 $620.00 $670.00 $436.00 $562.00 $592.00 $757.00 $865.00 $968.00 $1,004.00 $1,203.00 $834.00 $1,022.00 $1,166.00 $946.00 $913.00 $1,014.00 $468.00 $1,216.00 $1,214.00 $1,280.00 $1,043.00 $1,349.00 $1,294.00 $1,473.00 $723.00 $1,112.00 $1,388.00 $1,343.00 $1,554.00 $1,403.00 $1,401.00

FUD 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 25430 25431 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25606 25607 25608 25609 25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 25670 25671 25675 25676 25680

MRA $638.00 $631.00 $931.00 $1,147.00 $936.00 $970.00 $1,031.00 $959.00 $1,542.00 $952.00 $395.00 $805.00 $899.00 $955.00 $1,006.00 $1,170.00 $200.00 $517.00 $800.00 $644.00 $1,097.00 $1,293.00 $270.00 $516.00 $803.00 $276.00 $590.00 $804.00 $974.00 $312.00 $540.00 $643.00 $645.00 $739.00 $942.00 $148.00 $482.00 $716.00 $148.00 $458.00 $668.00 $185.00 $379.00 $560.00 $378.00 $731.00 $462.00 $404.00 $741.00 $471.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 25685 25690 25695 25800 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26111 26113 26115 26116 26117 26118 26121 26123 26125 26130 26135

MRA $887.00 $518.00 $520.00 $703.00 $1,078.00 $1,008.00 $2,276.00 $895.00 $991.00 $871.00 $900.00 $799.00 $849.00 $1,523.00 $771.00 $670.00 $768.00 $830.00 $645.00 $731.00 BR $59.00 $223.00 $484.00 $548.00 $655.00 $601.00 $741.00 $730.00 $367.00 $621.00 $343.00 $293.00 $440.00 $400.00 $382.00 $398.00 $481.00 $282.00 $423.00 $557.00 $344.00 $544.00 $806.00 $1,076.00 $833.00 $959.00 $342.00 $629.00 $668.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90

Part A, 80


Surgery CPT Code MRA 26140 $678.00 26145 $660.00 26160 $319.00 26170 $452.00 26180 $444.00 26185 $511.00 26200 $598.00 26205 $788.00 26210 $543.00 26215 $731.00 26230 $624.00 26235 $612.00 26236 $444.00 26250 $814.00 26260 $758.00 26262 $624.00 26320 $414.00 26340 $266.00 26341 $99.00 26350 $715.00 26352 $855.00 26356 $886.00 26357 $932.00 26358 $979.00 26370 $832.00 26372 $945.00 26373 $904.00 26390 $889.00 26392 $1,123.00 26410 $371.00 26412 $737.00 26415 $846.00 26416 $1,093.00 26418 $444.00 26420 $741.00 26426 $733.00 26428 $790.00 26432 $430.00 26433 $371.00 26434 $656.00 26437 $491.00 26440 $458.00 26442 $548.00 26445 $455.00 26449 $738.00 26450 $353.00 26455 $364.00 26460 $346.00 26471 $592.00 26474 $586.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 26560 26561 26562 26565 26567 26568 26580 26587 26590 26591

MRA $543.00 $553.00 $608.00 $653.00 $808.00 $986.00 $891.00 $738.00 $496.00 $971.00 $946.00 $949.00 $946.00 $1,317.00 $934.00 $557.00 $715.00 $334.00 $564.00 $630.00 $890.00 $877.00 $583.00 $531.00 $708.00 $877.00 $546.00 $770.00 $726.00 $926.00 $716.00 $722.00 $918.00 $665.00 $1,861.00 $3,901.00 $3,868.00 $4,551.00 $1,567.00 $4,005.00 $576.00 $1,067.00 $1,017.00 $730.00 $622.00 $1,003.00 $1,585.00 $792.00 $1,609.00 $431.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 26593 26596 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755 26756 26765 26770 26775 26776 26785 26820 26841 26842 26843 26844 26850 26852 26860 26861 26862 26863 26910 26951 26952 26989

MRA $587.00 $809.00 $133.00 $296.00 $334.00 $497.00 $521.00 $71.00 $371.00 $533.00 $693.00 $148.00 $501.00 $527.00 $592.00 $710.00 $88.00 $296.00 $469.00 $526.00 $96.00 $187.00 $187.00 $532.00 $148.00 $148.00 $548.00 $96.00 $133.00 $366.00 $398.00 $79.00 $275.00 $401.00 $408.00 $854.00 $756.00 $901.00 $800.00 $875.00 $704.00 $829.00 $542.00 $151.00 $747.00 $317.00 $747.00 $444.00 $608.00 BR

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 90 YYY

Part A, 81


Surgery CPT Code 26990 26991 26992 27000 27001 27003 27005 27006 27025 27027 27030 27033 27035 27036 27040 27041 27043 27045 27047 27048 27049 27050 27052 27054 27057 27059 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27080 27086 27087 27090 27091 27093 27095 27096 27097 27098 27100 27105 27110

MRA $592.00 $466.00 $1,146.00 $421.00 $550.00 $698.00 $738.00 $788.00 $896.00 $866.00 $1,148.00 $1,173.00 $1,413.00 $1,176.00 $196.00 $699.00 $476.00 $764.00 $535.00 $588.00 $1,162.00 $449.00 $624.00 $843.00 $972.00 $1,849.00 $491.00 $499.00 $583.00 $931.00 $1,234.00 $1,040.00 $1,112.00 $1,485.00 $1,859.00 $1,976.00 $1,164.00 $568.00 $57.00 $555.00 $981.00 $1,482.00 $62.00 $121.00 $491.00 $795.00 $799.00 $987.00 $946.00 $1,174.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 0 0 90 90 90 90 90

Surgery CPT Code 27111 27120 27122 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27194 27200 27202 27215 27216 27217 27218 27220 27222 27226 27227 27228 27230 27232 27235 27236 27238 27240 27244 27245 27246 27248 27250

MRA $1,099.00 $1,603.00 $1,406.00 $1,371.00 $1,853.00 $2,128.00 $2,576.00 $2,190.00 $2,025.00 $1,092.00 $1,432.00 $1,744.00 $1,732.00 $2,017.00 $1,588.00 $1,443.00 $1,572.00 $1,453.00 $491.00 $1,024.00 $1,257.00 $1,020.00 $1,107.00 $1,206.00 $676.00 $1,280.00 $425.00 $740.00 $180.00 $776.00 $954.00 $1,085.00 $1,285.00 $1,570.00 $444.00 $973.00 $1,350.00 $1,967.00 $2,195.00 $491.00 $916.00 $1,128.00 $1,421.00 $504.00 $1,043.00 $1,426.00 $1,691.00 $459.00 $980.00 $535.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0


Surgery CPT Code 27252 27253 27254 27256 27257 27258 27259 27265 27266 27267 27268 27269 27275 27279 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305 27306 27307 27310 27323 27324 27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27337 27339 27340 27345 27347 27350 27355 27356 27357 27358

MRA $520.00 $1,162.00 $1,478.00 $338.00 $455.00 $1,355.00 $1,803.00 $442.00 $614.00 $382.00 $470.00 $1,117.00 $220.00 $718.00 $1,179.00 $990.00 $1,435.00 $1,503.00 $2,073.00 $1,594.00 BR $193.00 $520.00 $555.00 $377.00 $503.00 $877.00 $211.00 $433.00 $476.00 $451.00 $400.00 $503.00 $1,249.00 $492.00 $585.00 $786.00 $719.00 $840.00 $959.00 $425.00 $765.00 $405.00 $565.00 $394.00 $786.00 $763.00 $882.00 $950.00 $394.00

FUD 90 90 90 10 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ

Part A, 82


Surgery CPT Code 27360 27364 27365 27370 27372 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27412 27415 27416 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 27457 27465

MRA $977.00 $1,601.00 $1,421.00 $75.00 $371.00 $698.00 $1,118.00 $753.00 $1,064.00 $506.00 $647.00 $834.00 $608.00 $748.00 $1,093.00 $742.00 $989.00 $832.00 $792.00 $842.00 $918.00 $1,212.00 $1,605.00 $1,340.00 $878.00 $1,596.00 $927.00 $930.00 $927.00 $639.00 $1,118.00 $1,266.00 $2,333.00 $884.00 $501.00 $819.00 $1,065.00 $1,064.00 $1,006.00 $1,117.00 $1,037.00 $1,618.00 $1,764.00 $1,960.00 $1,060.00 $1,311.00 $1,524.00 $1,157.00 $1,209.00 $1,253.00

FUD 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 27466 27468 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27500 27501 27502 27503 27506 27507 27508 27509 27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532 27535 27536 27538 27540 27550 27552 27556 27557 27558 27560 27562 27566 27570 27580 27590

MRA $1,441.00 $1,613.00 $1,501.00 $1,665.00 $782.00 $938.00 $1,123.00 $797.00 $1,771.00 $2,352.00 $1,438.00 $1,477.00 $563.00 $652.00 $701.00 $782.00 $520.00 $659.00 $909.00 $911.00 $1,522.00 $1,297.00 $400.00 $649.00 $755.00 $1,281.00 $1,562.00 $1,508.00 $579.00 $820.00 $1,311.00 $266.00 $910.00 $408.00 $641.00 $1,075.00 $1,282.00 $487.00 $1,106.00 $296.00 $619.00 $832.00 $1,479.00 $1,529.00 $88.00 $514.00 $1,047.00 $184.00 $1,644.00 $1,059.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90


Surgery CPT Code 27591 27592 27594 27596 27598 27599 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27616 27618 27619 27620 27625 27626 27630 27632 27634 27635 27637 27638 27640 27641 27645 27646 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685

MRA $1,182.00 $911.00 $600.00 $931.00 $976.00 BR $517.00 $516.00 $621.00 $412.00 $308.00 $236.00 $362.00 $608.00 $777.00 $701.00 $165.00 $327.00 $1,106.00 $1,297.00 $421.00 $730.00 $587.00 $796.00 $863.00 $430.00 $422.00 $697.00 $781.00 $921.00 $978.00 $1,122.00 $922.00 $1,302.00 $1,212.00 $1,044.00 $72.00 $869.00 $935.00 $937.00 $458.00 $527.00 $725.00 $504.00 $618.00 $656.00 $762.00 $523.00 $634.00 $565.00

FUD 90 90 90 90 90 YYY 90 90 90 90 90 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 83


Surgery CPT Code 27686 27687 27690 27691 27692 27695 27696 27698 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27726 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27767 27768 27769 27780 27781 27784 27786 27788 27792 27808 27810 27814 27816

MRA $706.00 $589.00 $757.00 $889.00 $159.00 $658.00 $758.00 $881.00 $835.00 $1,278.00 $1,337.00 $683.00 $985.00 $484.00 $1,118.00 $1,227.00 $1,285.00 $1,147.00 $1,076.00 $1,402.00 $1,312.00 $823.00 $1,175.00 $647.00 $611.00 $766.00 $1,044.00 $1,045.00 $940.00 $319.00 $614.00 $708.00 $1,115.00 $1,262.00 $223.00 $495.00 $759.00 $233.00 $361.00 $622.00 $244.00 $296.00 $643.00 $223.00 $422.00 $706.00 $332.00 $567.00 $972.00 $386.00

FUD 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 27818 27822 27823 27824 27825 27826 27827 27828 27829 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 27899 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28035 28039 28041 28043 28045 28046 28047 28050 28052 28054

MRA $613.00 $1,201.00 $1,472.00 $384.00 $670.00 $1,080.00 $1,310.00 $1,823.00 $742.00 $412.00 $415.00 $617.00 $334.00 $373.00 $877.00 $1,224.00 $211.00 $1,269.00 $843.00 $1,015.00 $1,120.00 $854.00 $579.00 $835.00 $911.00 $879.00 $575.00 $574.00 $712.00 BR $185.00 $362.00 $520.00 $520.00 $296.00 $235.00 $340.00 $509.00 $422.00 $371.00 $532.00 $525.00 $473.00 $305.00 $456.00 $814.00 $1,056.00 $414.00 $402.00 $236.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232

MRA $377.00 $495.00 $657.00 $476.00 $445.00 $392.00 $462.00 $414.00 $414.00 $330.00 $571.00 $700.00 $709.00 $491.00 $632.00 $517.00 $418.00 $421.00 $537.00 $457.00 $481.00 $890.00 $648.00 $568.00 $524.00 $601.00 $622.00 $480.00 $393.00 $727.00 $533.00 $416.00 $400.00 $412.00 $789.00 $747.00 $571.00 $75.00 $326.00 $341.00 $478.00 $613.00 $406.00 $609.00 $435.00 $555.00 $345.00 $334.00 $380.00 $286.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 84


Surgery CPT Code 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436

MRA $178.00 $695.00 $370.00 $535.00 $641.00 $881.00 $1,363.00 $912.00 $266.00 $336.00 $426.00 $463.00 $441.00 $452.00 $458.00 $557.00 $666.00 $845.00 $797.00 $832.00 $838.00 $755.00 $829.00 $845.00 $930.00 $776.00 $1,030.00 $530.00 $614.00 $516.00 $955.00 $505.00 $469.00 $436.00 $462.00 $833.00 $667.00 $649.00 $753.00 $414.00 $557.00 $1,197.00 $266.00 $473.00 $616.00 $1,354.00 $1,619.00 $110.00 $371.00 $463.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 28445 28446 28450 28455 28456 28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800

MRA $874.00 $1,075.00 $148.00 $321.00 $288.00 $533.00 $178.00 $296.00 $364.00 $521.00 $80.00 $133.00 $261.00 $399.00 $75.00 $115.00 $345.00 $120.00 $243.00 $145.00 $208.00 $325.00 $592.00 $189.00 $308.00 $382.00 $742.00 $144.00 $287.00 $487.00 $621.00 $145.00 $189.00 $318.00 $434.00 $106.00 $172.00 $309.00 $348.00 $1,353.00 $1,179.00 $1,015.00 $945.00 $961.00 $873.00 $690.00 $690.00 $466.00 $654.00 $731.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 28805 28810 28820 28825 28890 28899 29000 29010 29015 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580 29581 29582

MRA $731.00 $543.00 $377.00 $339.00 $358.00 BR $247.00 $271.00 $289.00 $213.00 $260.00 $260.00 $286.00 $45.00 $180.00 $110.00 $88.00 $72.00 $59.00 $54.00 $59.00 $45.00 $53.00 $26.00 $53.00 $29.00 $45.00 $26.00 $29.00 $223.00 $260.00 $126.00 $133.00 $241.00 $101.00 $96.00 $101.00 $133.00 $22.00 $214.00 $84.00 $75.00 $59.00 $22.00 $55.00 $41.00 $37.00 $39.00 $62.00 $71.00

FUD 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Part A, 85


Surgery CPT Code 29583 29584 29700 29705 29710 29720 29730 29740 29750 29799 29800 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29866 29867 29868 29870

MRA $44.00 $71.00 $29.00 $26.00 $29.00 $29.00 $29.00 $37.00 $105.00 BR $557.00 $902.00 $360.00 $1,003.00 $976.00 $756.00 $718.00 $863.00 $749.00 $1,330.00 $611.00 $941.00 $980.00 $1,058.00 $830.00 $524.00 $635.00 $612.00 $680.00 $830.00 $931.00 $501.00 $580.00 $612.00 $931.00 $976.00 $1,277.00 $608.00 $752.00 $1,137.00 $1,007.00 $1,231.00 $658.00 $845.00 $907.00 $880.00 $1,046.00 $1,250.00 $1,694.00 $460.00

FUD 0 0 0 0 0 0 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29899 29900 29901 29902 29904 29905 29906 29907 29914 29915 29916 29999 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160

MRA $631.00 $489.00 $676.00 $639.00 $809.00 $852.00 $1,064.00 $1,169.00 $745.00 $819.00 $1,235.00 $721.00 $832.00 $697.00 $949.00 $1,296.00 $1,255.00 $796.00 $835.00 $472.00 $690.00 $679.00 $704.00 $863.00 $973.00 $434.00 $479.00 $514.00 $557.00 $601.00 $633.00 $775.00 $1,036.00 $1,057.00 $1,057.00 BR $96.00 $117.00 $86.00 $157.00 $360.00 $301.00 $819.00 $500.00 $243.00 $599.00 $275.00 $320.00 $790.00 $875.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 0 10 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 30462 30465 30520 30540 30545 30560 30580 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 30999 31000 31002 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090

MRA $68.00 $75.00 $154.00 $45.00 $170.00 $419.00 $741.00 $1,173.00 $1,424.00 $626.00 $1,005.00 $1,445.00 $857.00 $1,633.00 $803.00 $533.00 $643.00 $981.00 $104.00 $566.00 $466.00 $564.00 $624.00 $88.00 $172.00 $75.00 $110.00 $224.00 $208.00 $596.00 $862.00 $213.00 BR $81.00 $135.00 $281.00 $531.00 $604.00 $772.00 $489.00 $654.00 $410.00 $839.00 $942.00 $1,089.00 $1,210.00 $1,281.00 $1,081.00 $1,075.00 $877.00

FUD 0 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 10 10 0 0 0 0 90 90 10 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 86


Surgery CPT Code 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238 31239 31240 31254 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31295 31296 31297 31299 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515

MRA $463.00 $716.00 $851.00 $1,683.00 $1,908.00 $122.00 $221.00 $217.00 $266.00 $311.00 $775.00 $224.00 $588.00 $601.00 $292.00 $453.00 $690.00 $339.00 $396.00 $1,462.00 $1,551.00 $1,235.00 $1,346.00 $1,587.00 $2,104.00 $2,136.00 $2,101.00 BR $1,295.00 $508.00 $1,630.00 $2,238.00 $1,913.00 $2,478.00 $1,891.00 $1,720.00 $1,782.00 $1,822.00 $2,513.00 $2,937.00 $969.00 $969.00 $116.00 $74.00 $62.00 $145.00 $88.00 $197.00 $182.00 $160.00

FUD 90 90 90 90 90 0 0 0 0 0 10 0 0 0 0 0 0 0 0 10 10 10 10 10 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0

Surgery CPT Code 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540 31541 31545 31546 31560 31561 31570 31571 31575 31576 31577 31578 31579 31580 31582 31584 31587 31588 31590 31595 31599 31600 31603 31605 31610 31611 31612 31613 31614 31615 31622 31623 31624 31625 31626 31627 31628 31629 31630 31631 31632

MRA $234.00 $222.00 $262.00 $202.00 $217.00 $284.00 $311.00 $272.00 $308.00 $357.00 $453.00 $384.00 $587.00 $446.00 $509.00 $369.00 $363.00 $128.00 $186.00 $230.00 $264.00 $219.00 $1,213.00 $1,881.00 $1,616.00 $913.00 $1,206.00 $691.00 $773.00 BR $306.00 $343.00 $297.00 $794.00 $614.00 $99.00 $384.00 $736.00 $213.00 $230.00 $225.00 $217.00 $235.00 $450.00 $1,310.00 $269.00 $198.00 $308.00 $252.00 $73.00

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 YYY 0 0 0 90 90 0 90 90 0 0 0 0 0 0 ZZZ 0 0 0 0 ZZZ


Surgery CPT Code 31633 31634 31635 31636 31637 31638 31640 31641 31643 31645 31646 31647 31648 31649 31651 31652 31653 31654 31660 31661 31717 31720 31725 31730 31750 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800 31805 31820 31825 31830 31899 32035 32036 32096 32097 32098 32100 32110 32120 32124 32140

MRA $90.00 $1,886.00 $298.00 $241.00 $86.00 $268.00 $399.00 $304.00 $208.00 $208.00 $161.00 $228.00 $218.00 $71.00 $82.00 $921.00 $979.00 $147.00 $218.00 $230.00 $138.00 $89.00 $103.00 $199.00 $1,088.00 $1,448.00 $1,648.00 $2,315.00 $1,815.00 $1,973.00 $1,577.00 $1,936.00 $1,320.00 $1,866.00 $628.00 $1,175.00 $458.00 $659.00 $460.00 BR $821.00 $908.00 $835.00 $836.00 $789.00 $1,120.00 $1,223.00 $1,077.00 $1,144.00 $1,284.00

FUD ZZZ 0 0 0 ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90

Part A, 87


Surgery CPT Code 32141 32150 32151 32160 32200 32215 32220 32225 32310 32320 32400 32405 32440 32442 32445 32480 32482 32484 32486 32488 32491 32501 32503 32504 32505 32506 32507 32540 32550 32551 32552 32553 32554 32555 32556 32557 32560 32561 32562 32601 32604 32606 32607 32608 32609 32650 32651 32652 32653 32654

MRA $1,267.00 $1,226.00 $1,231.00 $842.00 $1,132.00 $1,024.00 $1,680.00 $1,268.00 $1,221.00 $1,787.00 $129.00 $159.00 $1,837.00 $2,093.00 $2,093.00 $1,622.00 $1,714.00 $1,771.00 $1,974.00 $2,094.00 $1,784.00 $374.00 $1,875.00 $2,145.00 $964.00 $164.00 $164.00 $1,308.00 $821.00 $171.00 $196.00 $597.00 $201.00 $300.00 $542.00 $578.00 $302.00 $97.00 $87.00 $456.00 $663.00 $637.00 $321.00 $394.00 $272.00 $957.00 $1,166.00 $1,615.00 $1,144.00 $1,096.00

FUD 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ ZZZ 90 0 0 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90

Surgery CPT Code 32655 32656 32658 32659 32661 32662 32663 32664 32665 32666 32667 32668 32669 32670 32671 32672 32673 32674 32701 32800 32810 32815 32820 32851 32852 32853 32854 32900 32905 32906 32940 32960 32997 32998 32999 33010 33011 33015 33020 33025 33030 33031 33050 33120 33130 33140 33141 33202 33203 33206

MRA $1,213.00 $1,222.00 $1,142.00 $1,141.00 $1,165.00 $1,459.00 $1,636.00 $1,197.00 $1,360.00 $902.00 $164.00 $164.00 $1,395.00 $1,658.00 $1,847.00 $1,584.00 $1,251.00 $224.00 $229.00 $1,166.00 $1,085.00 $1,917.00 $1,848.00 $3,100.00 $3,339.00 $3,787.00 $4,038.00 $1,532.00 $1,661.00 $2,100.00 $1,555.00 $126.00 $312.00 $2,809.00 BR $124.00 $125.00 $555.00 $1,178.00 $1,165.00 $1,786.00 $1,816.00 $1,224.00 $2,358.00 $1,734.00 $1,571.00 $254.00 $749.00 $766.00 $642.00

FUD 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 YYY 0 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90


Surgery CPT Code 33207 33208 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33221 33222 33223 33224 33225 33226 33227 33228 33229 33230 33231 33233 33234 33235 33236 33237 33238 33240 33241 33243 33244 33249 33250 33251 33254 33255 33256 33257 33258 33259 33261 33262 33263 33264 33265 33266 33270 33271

MRA $753.00 $573.00 $204.00 $210.00 $511.00 $437.00 $532.00 $304.00 $402.00 $428.00 $488.00 $390.00 $379.00 $471.00 $585.00 $490.00 $434.00 $472.00 $359.00 $374.00 $393.00 $408.00 $421.00 $270.00 $598.00 $587.00 $933.00 $1,184.00 $1,235.00 $648.00 $301.00 $1,650.00 $1,081.00 $1,271.00 $1,687.00 $2,071.00 $1,307.00 $1,573.00 $1,879.00 $565.00 $639.00 $839.00 $1,993.00 $394.00 $409.00 $427.00 $1,307.00 $1,789.00 $614.00 $517.00

FUD 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90

Part A, 88


Surgery CPT Code 33272 33273 33282 33284 33300 33305 33310 33315 33320 33321 33322 33330 33335 33361 33362 33363 33364 33365 33366 33367 33368 33369 33400 33401 33403 33404 33405 33406 33410 33411 33412 33413 33414 33415 33416 33417 33418 33419 33420 33422 33425 33426 33427 33430 33460 33463 33464 33465 33468 33470

MRA $364.00 $418.00 $470.00 $365.00 $1,576.00 $1,889.00 $1,577.00 $1,875.00 $1,485.00 $1,890.00 $1,935.00 $1,726.00 $2,336.00 $1,404.00 $1,535.00 $1,589.00 $1,671.00 $1,843.00 $1,995.00 $644.00 $780.00 $1,030.00 $2,401.00 $2,228.00 $2,369.00 $2,698.00 $2,745.00 $2,962.00 $2,637.00 $2,981.00 $3,213.00 $3,282.00 $2,904.00 $2,563.00 $2,684.00 $2,756.00 $1,871.00 $440.00 $1,796.00 $2,431.00 $2,509.00 $2,806.00 $3,026.00 $2,891.00 $2,215.00 $2,396.00 $2,547.00 $2,665.00 $2,952.00 $1,749.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 33471 33474 33475 33476 33477 33478 33496 33500 33501 33502 33503 33504 33505 33506 33507 33508 33510 33511 33512 33513 33514 33516 33517 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33545 33548 33572 33600 33602 33606 33608 33610 33611 33612 33615 33617 33619 33620 33621 33622

MRA $1,929.00 $2,173.00 $2,666.00 $2,270.00 $1,345.00 $2,544.00 $2,595.00 $2,370.00 $1,546.00 $1,938.00 $1,983.00 $2,416.00 $2,423.00 $2,448.00 $1,809.00 $17.00 $2,354.00 $2,546.00 $2,732.00 $2,933.00 $3,197.00 $3,404.00 $219.00 $414.00 $607.00 $801.00 $994.00 $1,189.00 $521.00 $2,415.00 $2,654.00 $2,899.00 $3,143.00 $2,693.00 $3,250.00 $2,381.00 $340.00 $2,644.00 $2,556.00 $2,831.00 $2,940.00 $2,871.00 $2,985.00 $3,152.00 $3,051.00 $3,272.00 $3,678.00 $1,527.00 $914.00 $3,597.00

FUD 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 33641 33645 33647 33660 33665 33670 33675 33676 33677 33681 33684 33688 33690 33692 33694 33697 33702 33710 33720 33722 33724 33726 33730 33732 33735 33736 33737 33750 33755 33762 33764 33766 33767 33768 33770 33771 33774 33775 33776 33777 33778 33779 33780 33781 33782 33783 33786 33788 33800 33802

MRA $1,981.00 $2,352.00 $2,732.00 $2,444.00 $2,700.00 $2,820.00 $2,085.00 $2,151.00 $2,236.00 $2,657.00 $2,740.00 $2,602.00 $1,884.00 $2,816.00 $2,856.00 $3,064.00 $2,549.00 $2,731.00 $2,508.00 $2,704.00 $1,491.00 $1,963.00 $2,785.00 $2,622.00 $2,036.00 $2,288.00 $1,977.00 $1,877.00 $1,831.00 $1,900.00 $1,895.00 $2,119.00 $2,173.00 $449.00 $2,954.00 $2,924.00 $2,681.00 $2,654.00 $2,844.00 $2,724.00 $3,199.00 $3,121.00 $3,232.00 $3,057.00 $3,439.00 $3,834.00 $2,970.00 $2,288.00 $1,546.00 $1,752.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 89


Surgery CPT Code 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853 33860 33863 33864 33870 33875 33877 33880 33881 33883 33884 33886 33889 33891 33910 33915 33916 33917 33920 33922 33924 33925 33926 33935 33945 33946 33947 33948 33949 33951 33952 33953 33954 33955 33956 33957 33958 33959 33962 33963

MRA $1,746.00 $1,935.00 $2,464.00 $1,619.00 $1,559.00 $1,884.00 $2,029.00 $2,129.00 $2,129.00 $2,311.00 $3,057.00 $3,044.00 $3,183.00 $3,035.00 $3,638.00 $2,876.00 $3,767.00 $1,866.00 $1,603.00 $1,187.00 $441.00 $1,025.00 $882.00 $1,126.00 $1,987.00 $1,588.00 $2,096.00 $2,345.00 $2,981.00 $2,227.00 $421.00 $1,849.00 $2,499.00 $5,415.00 $3,813.00 $319.00 $353.00 $252.00 $245.00 $435.00 $449.00 $486.00 $502.00 $873.00 $875.00 $194.00 $191.00 $246.00 $249.00 $493.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 0 0 90 90 90 90 90 90 ZZZ 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Surgery CPT Code 33964 33965 33966 33967 33968 33969 33970 33971 33973 33974 33975 33976 33977 33978 33979 33980 33981 33982 33983 33984 33985 33986 33987 33988 33989 33990 33991 33992 33993 33999 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471 34490 34501 34502 34510 34520 34530 34800 34802 34803

MRA $513.00 $194.00 $246.00 $258.00 $51.00 $287.00 $576.00 $578.00 $756.00 $1,095.00 $1,758.00 $2,056.00 $1,561.00 $1,754.00 $2,496.00 $3,212.00 $879.00 $2,052.00 $2,418.00 $298.00 $541.00 $554.00 $218.00 $812.00 $525.00 $454.00 $662.00 $215.00 $188.00 BR $1,012.00 $1,134.00 $800.00 $669.00 $1,288.00 $777.00 $949.00 $953.00 $779.00 $1,117.00 $685.00 $660.00 $910.00 $2,044.00 $1,108.00 $1,077.00 $1,368.00 $1,159.00 $1,279.00 $1,372.00

FUD 0 0 0 0 0 0 0 90 0 90 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 34804 34805 34806 34808 34812 34813 34820 34825 34826 34830 34831 34832 34833 34834 34900 35001 35002 35005 35011 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152 35180 35182 35184 35188 35189 35190 35201 35206 35207 35211 35216

MRA $1,279.00 $1,243.00 $100.00 $220.00 $359.00 $256.00 $519.00 $694.00 $220.00 $1,803.00 $1,950.00 $1,950.00 $650.00 $306.00 $960.00 $1,564.00 $1,547.00 $1,268.00 $1,007.00 $1,376.00 $1,635.00 $1,686.00 $995.00 $2,175.00 $2,661.00 $2,634.00 $2,872.00 $2,346.00 $2,587.00 $1,398.00 $1,351.00 $2,000.00 $2,382.00 $1,495.00 $1,742.00 $1,231.00 $1,339.00 $1,390.00 $1,229.00 $997.00 $1,345.00 $976.00 $1,048.00 $1,380.00 $1,018.00 $852.00 $835.00 $935.00 $1,833.00 $1,494.00

FUD 90 90 ZZZ ZZZ 0 ZZZ 0 90 ZZZ 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 90


Surgery CPT Code 35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286 35301 35302 35303 35304 35305 35306 35311 35321 35331 35341 35351 35355 35361 35363 35371 35372 35390 35400 35450 35452 35458 35460 35471 35472 35475 35476 35500 35501 35506 35508 35509 35510 35511 35512 35515 35516

MRA $1,243.00 $841.00 $1,053.00 $947.00 $1,926.00 $1,701.00 $1,260.00 $1,568.00 $1,008.00 $921.00 $1,814.00 $1,541.00 $1,396.00 $1,036.00 $1,486.00 $1,109.00 $1,218.00 $1,267.00 $1,218.00 $456.00 $1,999.00 $1,031.00 $1,724.00 $1,908.00 $1,555.00 $1,336.00 $1,859.00 $2,006.00 $1,006.00 $1,085.00 $225.00 $224.00 $643.00 $518.00 $804.00 $430.00 $626.00 $388.00 $569.00 $338.00 $423.00 $1,569.00 $1,641.00 $1,564.00 $1,529.00 $1,316.00 $1,256.00 $1,291.00 $1,387.00 $1,391.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 0 0 0 0 0 0 0 0 ZZZ 90 90 90 90 90 90 90 90 90

Surgery CPT Code 35518 35521 35522 35523 35525 35526 35531 35533 35535 35536 35537 35538 35539 35540 35556 35558 35560 35563 35565 35566 35570 35571 35572 35583 35585 35587 35600 35601 35606 35612 35616 35621 35623 35626 35631 35632 35633 35634 35636 35637 35638 35642 35645 35646 35647 35650 35654 35656 35661 35663

MRA $1,313.00 $1,393.00 $1,253.00 $1,237.00 $1,197.00 $1,527.00 $2,000.00 $1,716.00 $1,816.00 $1,888.00 $2,141.00 $2,391.00 $2,248.00 $2,505.00 $1,745.00 $1,219.00 $1,899.00 $1,115.00 $1,312.00 $2,161.00 $1,455.00 $1,612.00 $369.00 $1,843.00 $2,277.00 $1,698.00 $273.00 $1,495.00 $1,539.00 $1,349.00 $1,346.00 $1,265.00 $1,193.00 $1,921.00 $1,891.00 $1,725.00 $1,926.00 $1,688.00 $1,656.00 $1,704.00 $1,731.00 $1,298.00 $1,304.00 $2,105.00 $1,555.00 $1,236.00 $1,603.00 $1,589.00 $1,145.00 $1,237.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 35665 35666 35671 35681 35682 35683 35685 35686 35691 35693 35694 35695 35697 35700 35701 35721 35741 35761 35800 35820 35840 35860 35870 35875 35876 35879 35881 35883 35884 35901 35903 35905 35907 36000 36002 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36147 36148 36160 36200 36215

MRA $1,333.00 $1,686.00 $1,315.00 $751.00 $627.00 $702.00 $216.00 $178.00 $1,546.00 $1,140.00 $1,353.00 $1,351.00 $166.00 $264.00 $494.00 $500.00 $499.00 $532.00 $567.00 $951.00 $771.00 $496.00 $1,583.00 $827.00 $1,232.00 $1,163.00 $1,275.00 $1,247.00 $1,324.00 $709.00 $818.00 $1,343.00 $1,335.00 $46.00 $181.00 $68.00 $136.00 $194.00 $186.00 $141.00 $159.00 $186.00 $176.00 $120.00 $106.00 $853.00 $265.00 $196.00 $240.00 $240.00

FUD 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0

Part A, 91


Surgery CPT Code 36216 36217 36218 36221 36222 36223 36224 36225 36226 36227 36228 36245 36246 36247 36248 36251 36252 36253 36254 36260 36261 36262 36299 36410 36415 36416 36425 36430 36455 36468 36470 36471 36475 36476 36478 36479 36481 36500 36511 36512 36513 36514 36515 36516 36522 36556 36558 36561 36563 36565

MRA $270.00 $325.00 $79.00 $1,132.00 $1,433.00 $1,560.00 $1,715.00 $1,545.00 $1,749.00 $253.00 $1,190.00 $249.00 $272.00 $323.00 $53.00 $1,436.00 $1,561.00 $2,307.00 $2,211.00 $749.00 $388.00 $297.00 BR $18.00 BR BR $86.00 $37.00 $141.00 BR $76.00 $96.00 $2,216.00 $434.00 $2,041.00 $438.00 $499.00 $159.00 $92.00 $92.00 $92.00 $92.00 $92.00 $92.00 $305.00 $316.00 $703.00 $1,333.00 $1,679.00 $1,073.00

FUD 0 0 ZZZ 0 0 0 0 0 0 ZZZ ZZZ 0 0 0 ZZZ 0 0 0 0 90 90 90 YYY 0 0 0 0 0 0 0 10 10 0 ZZZ 0 ZZZ 0 0 0 0 0 0 0 0 0 0 10 10 10 10

Surgery CPT Code 36566 36569 36571 36575 36576 36578 36580 36581 36582 36583 36584 36585 36589 36590 36591 36592 36593 36595 36596 36597 36598 36600 36620 36625 36640 36680 36800 36810 36815 36818 36819 36820 36821 36823 36825 36830 36831 36832 36833 36835 36838 36860 36861 36870 37140 37145 37160 37180 37181 37182

MRA $1,121.00 $350.00 $1,550.00 $172.00 $429.00 $546.00 $307.00 $646.00 $1,210.00 $708.00 $321.00 $1,525.00 $176.00 $378.00 $21.00 $26.00 $37.00 $880.00 $194.00 $167.00 $130.00 $24.00 $64.00 $133.00 $130.00 $72.00 $159.00 $345.00 $236.00 $736.00 $977.00 $800.00 $721.00 $1,461.00 $867.00 $967.00 $488.00 $810.00 $780.00 $542.00 $1,230.00 $166.00 $224.00 $1,755.00 $1,666.00 $1,741.00 $1,681.00 $1,769.00 $1,923.00 $914.00

FUD 10 0 10 0 10 10 0 10 10 10 0 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 0


Surgery CPT Code 37183 37184 37185 37186 37187 37188 37191 37192 37193 37195 37197 37200 37211 37212 37213 37214 37215 37217 37218 37220 37221 37222 37223 37224 37225 37226 37227 37228 37229 37230 37231 37232 37233 37234 37235 37236 37237 37238 37239 37241 37242 37243 37244 37252 37253 37500 37501 37565 37600 37605

MRA $425.00 $3,074.00 $1,002.00 $2,076.00 $2,991.00 $2,586.00 $2,683.00 $1,555.00 $1,638.00 $302.00 $1,541.00 $232.00 $419.00 $370.00 $258.00 $152.00 $1,095.00 $1,164.00 $861.00 $3,236.00 $4,750.00 $911.00 $2,638.00 $3,919.00 $11,190.00 $9,188.00 $15,065.00 $5,569.00 $11,021.00 $8,434.00 $13,463.00 $1,238.00 $1,486.00 $3,935.00 $4,017.00 $2,863.00 $1,243.00 $4,186.00 $2,081.00 $4,634.00 $7,805.00 $9,853.00 $6,899.00 $1,426.00 $222.00 $739.00 BR $364.00 $414.00 $521.00

FUD 0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ ZZZ 0 ZZZ 0 ZZZ 0 0 0 0 ZZZ ZZZ 90 YYY 90 90 90

Part A, 92


Surgery CPT Code 37606 37607 37609 37615 37616 37617 37618 37619 37650 37660 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 37788 37790 37799 38100 38101 38102 38115 38120 38129 38200 38205 38206 38220 38221 38230 38232 38240 38241 38242 38243 38300 38305 38308 38380 38381 38382 38500 38505 38510 38520

MRA $563.00 $456.00 $278.00 $495.00 $1,128.00 $1,132.00 $514.00 $1,712.00 $430.00 $789.00 $336.00 $416.00 $495.00 $847.00 $813.00 $577.00 $462.00 $561.00 $301.00 $270.00 $1,654.00 $690.00 BR $974.00 $982.00 $332.00 $1,020.00 $1,138.00 BR $180.00 $79.00 $79.00 $212.00 $228.00 $265.00 $214.00 $128.00 $128.00 $90.00 $121.00 $104.00 $375.00 $425.00 $628.00 $1,087.00 $798.00 $234.00 $139.00 $349.00 $431.00

FUD 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 10 90 90 90 90 90 10 0 10 90

Surgery CPT Code 38525 38530 38542 38550 38555 38562 38564 38570 38571 38572 38589 38700 38720 38724 38740 38745 38746 38747 38760 38765 38770 38780 38790 38792 38794 38900 38999 39000 39010 39200 39220 39401 39402 39499 39501 39503 39540 39541 39545 39560 39561 39599 40490 40500 40510 40520 40525 40527 40530 40650

MRA $369.00 $517.00 $507.00 $519.00 $1,115.00 $799.00 $831.00 $695.00 $902.00 $1,049.00 BR $863.00 $1,328.00 $1,366.00 $539.00 $770.00 $312.00 $337.00 $699.00 $1,283.00 $1,111.00 $1,357.00 $158.00 $26.00 $298.00 $141.00 BR $664.00 $1,148.00 $1,249.00 $1,542.00 $324.00 $423.00 BR $1,083.00 $2,726.00 $1,133.00 $1,179.00 $1,102.00 $968.00 $1,328.00 BR $108.00 $422.00 $469.00 $467.00 $714.00 $851.00 $501.00 $368.00

FUD 90 90 90 90 90 90 90 10 10 10 YYY 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 0 0 90 ZZZ YYY 90 90 90 90 0 0 YYY 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90


Surgery CPT Code 40652 40654 40700 40701 40702 40720 40761 40799 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 40899 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41019 41100 41105 41108 41110 41112 41113 41114 41115 41116

MRA $436.00 $529.00 $1,009.00 $1,452.00 $1,030.00 $1,107.00 $1,202.00 BR $110.00 $208.00 $105.00 $245.00 $38.00 $100.00 $141.00 $202.00 $319.00 $336.00 $249.00 $208.00 $104.00 $140.00 $213.00 $687.00 $684.00 $947.00 $1,232.00 $1,593.00 BR $119.00 $109.00 $237.00 $283.00 $248.00 $319.00 $91.00 $267.00 $357.00 $300.00 $424.00 $444.00 $140.00 $136.00 $110.00 $159.00 $255.00 $301.00 $682.00 $176.00 $242.00

FUD 90 90 90 90 90 90 90 YYY 10 10 10 10 0 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 YYY 10 10 90 90 90 90 10 90 90 90 90 0 10 10 10 10 90 90 90 10 90

Part A, 93


Surgery CPT Code 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41512 41520 41530 41599 41800 41805 41806 41820 41821 41822 41823 41825 41826 41827 41828 41830 41850 41870 41872 41874 41899 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220

MRA $813.00 $937.00 $1,869.00 $2,005.00 $2,406.00 $1,897.00 $2,091.00 $2,448.00 $168.00 $203.00 $294.00 $334.00 $313.00 $644.00 $255.00 $3,327.00 BR $107.00 $115.00 $217.00 BR BR $237.00 $312.00 $144.00 $211.00 $322.00 $176.00 $156.00 BR BR $249.00 $193.00 BR $106.00 $122.00 $161.00 $204.00 $409.00 $573.00 $174.00 $741.00 $176.00 $222.00 $324.00 $946.00 $863.00 $1,174.00 $766.00 $586.00

FUD 90 90 90 90 90 90 90 90 10 10 10 90 90 90 90 0 YYY 10 10 10 0 0 10 90 10 10 90 10 10 0 0 90 90 YYY 10 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90

Surgery CPT Code 42225 42226 42227 42235 42260 42280 42281 42299 42300 42305 42310 42320 42330 42335 42340 42400 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42509 42510 42550 42600 42650 42660 42665 42699 42700 42720 42725 42800 42804 42806 42808 42809 42810 42815 42821 42826 42831

MRA $803.00 $848.00 $762.00 $631.00 $491.00 $148.00 $160.00 BR $165.00 $448.00 $145.00 $208.00 $184.00 $287.00 $411.00 $94.00 $258.00 $377.00 $266.00 $746.00 $1,364.00 $1,577.00 $1,097.00 $1,882.00 $634.00 $395.00 $407.00 $559.00 $522.00 $915.00 $711.00 $82.00 $445.00 $67.00 $89.00 $238.00 BR $144.00 $270.00 $720.00 $123.00 $136.00 $167.00 $250.00 $152.00 $335.00 $659.00 $378.00 $320.00 $235.00

FUD 90 90 90 90 90 10 10 YYY 10 90 10 10 10 90 90 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 0 90 YYY 10 10 90 10 10 10 10 10 90 90 90 90 90


Surgery CPT Code 42836 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 42960 42961 42962 42970 42971 42972 42999 43020 43030 43045 43100 43101 43107 43108 43112 43113 43116 43117 43118 43121 43122 43123 43124 43130 43135 43180 43191 43192 43193 43194 43195 43196 43197 43198 43200 43201 43202

MRA $286.00 $729.00 $1,173.00 $1,958.00 $207.00 $427.00 $1,047.00 $1,262.00 $1,825.00 $429.00 $745.00 $752.00 $561.00 $178.00 $406.00 $602.00 $284.00 $472.00 $562.00 BR $696.00 $712.00 $1,574.00 $744.00 $1,248.00 $2,325.00 $2,664.00 $2,471.00 $2,755.00 $2,509.00 $2,469.00 $2,607.00 $2,350.00 $2,287.00 $2,661.00 $2,242.00 $1,020.00 $1,332.00 $573.00 $130.00 $155.00 $185.00 $168.00 $186.00 $203.00 $188.00 $210.00 $266.00 $245.00 $205.00

FUD 90 90 90 90 90 90 90 90 90 10 90 90 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0

Part A, 94


Surgery CPT Code MRA 43204 $228.00 43205 $207.00 43206 $337.00 43210 $444.00 43211 $253.00 43212 $200.00 43213 $1,253.00 43214 $203.00 43215 $160.00 43216 $149.00 43217 $176.00 43220 $128.00 43226 $142.00 43227 $218.00 43229 $739.00 43231 $182.00 43232 $252.00 43233 $241.00 43235 $239.00 43236 $285.00 43237 $219.00 43238 $271.00 43239 $246.00 43240 $369.00 43241 $157.00 43242 $384.00 43243 $276.00 43244 $268.00 43245 $214.00 43246 $485.00 43247 $229.00 43248 $191.00 43249 $175.00 43250 $194.00 43251 $224.00 43252 $376.00 43253 $280.00 43254 $291.00 43255 $343.00 43257 $305.00 43259 $271.00 43260 $349.00 43261 $362.00 43262 $447.00 43263 $386.00 43264 $522.00 43265 $527.00 43266 $241.00 43270 $737.00 43273 $129.00

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ

Surgery CPT Code 43274 43275 43276 43277 43278 43279 43280 43281 43282 43283 43289 43300 43305 43310 43312 43313 43314 43320 43325 43327 43328 43330 43331 43332 43333 43334 43335 43336 43337 43338 43340 43341 43351 43352 43360 43361 43400 43401 43405 43410 43415 43420 43425 43450 43453 43460 43496 43499 43500 43501

MRA $498.00 $411.00 $518.00 $413.00 $470.00 $1,319.00 $1,314.00 $1,577.00 $1,774.00 $161.00 BR $837.00 $1,428.00 $2,138.00 $2,331.00 $2,632.00 $2,891.00 $1,299.00 $1,261.00 $838.00 $1,193.00 $1,236.00 $1,378.00 $1,188.00 $1,292.00 $1,282.00 $1,374.00 $1,557.00 $1,681.00 $120.00 $1,292.00 $1,351.00 $1,180.00 $1,028.00 $2,277.00 $2,596.00 $1,261.00 $1,299.00 $1,330.00 $946.00 $1,382.00 $854.00 $1,338.00 $91.00 $102.00 $203.00 BR BR $649.00 $1,105.00

FUD 0 0 0 0 0 90 90 90 90 ZZZ YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 YYY 90 90


Surgery CPT Code 43502 43510 43520 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635 43640 43641 43644 43645 43651 43652 43653 43659 43752 43753 43754 43755 43756 43757 43760 43761 43770 43771 43772 43773 43774 43775 43800 43810 43820 43825 43830 43831 43832 43840 43843 43845 43846 43847 43848 43850

MRA $1,247.00 $680.00 $599.00 $686.00 $861.00 $1,001.00 $1,691.00 $1,718.00 $1,798.00 $1,445.00 $1,443.00 $1,467.00 $1,786.00 $143.00 $1,119.00 $1,138.00 $1,598.00 $1,724.00 $716.00 $856.00 $617.00 BR $36.00 $21.00 $92.00 $140.00 $214.00 $301.00 $81.00 $107.00 $1,009.00 $1,162.00 $885.00 $1,162.00 $888.00 $1,146.00 $793.00 $846.00 $896.00 $1,128.00 $592.00 $593.00 $904.00 $893.00 $1,249.00 $1,738.00 $1,528.00 $1,678.00 $1,795.00 $1,425.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 95


Surgery CPT Code 43855 43860 43865 43870 43880 43886 43887 43888 43999 44005 44010 44015 44020 44021 44025 44050 44055 44100 44110 44111 44120 44121 44125 44126 44127 44128 44130 44133 44136 44139 44140 44141 44143 44144 44145 44146 44147 44150 44151 44155 44156 44157 44158 44160 44180 44186 44187 44188 44202 44203

MRA $1,454.00 $1,435.00 $1,549.00 $590.00 $1,352.00 $280.00 $274.00 $389.00 BR $1,171.00 $809.00 $1,171.00 $891.00 $888.00 $905.00 $862.00 $957.00 $117.00 $784.00 $963.00 $1,078.00 $308.00 $1,135.00 $1,951.00 $2,243.00 $242.00 $938.00 BR BR $154.00 $1,350.00 $1,488.00 $1,536.00 $1,442.00 $1,678.00 $1,840.00 $1,452.00 $1,661.00 $1,499.00 $1,892.00 $1,709.00 $1,952.00 $2,003.00 $1,236.00 $853.00 $600.00 $992.00 $1,088.00 $1,603.00 $235.00

FUD 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 ZZZ 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ

Surgery CPT Code 44204 44205 44206 44207 44208 44210 44211 44212 44213 44227 44238 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44381 44382 44384 44385 44386 44388 44388-53 44389 44390 44391 44392 44394 44401 44402

MRA $1,353.00 $1,198.00 $1,480.00 $1,620.00 $1,752.00 $1,551.00 $1,926.00 $1,800.00 $196.00 $1,536.00 BR $697.00 $950.00 $453.00 $892.00 $1,229.00 $1,029.00 $1,015.00 $397.00 $816.00 $923.00 $177.00 $195.00 $213.00 $255.00 $226.00 $300.00 $308.00 $253.00 $301.00 $238.00 $305.00 $320.00 $410.00 $396.00 $91.00 $1,016.00 $110.00 $164.00 $219.00 $183.00 $326.00 $178.00 $301.00 $319.00 $376.00 $359.00 $395.00 $3,308.00 $282.00

FUD 90 90 90 90 90 90 90 90 ZZZ 90 YYY 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0


Surgery CPT Code 44403 44404 44405 44406 44407 44408 44500 44602 44603 44604 44605 44615 44620 44625 44626 44640 44650 44660 44661 44680 44700 44701 44720 44721 44799 44800 44820 44850 44899 44900 44950 44955 44960 44970 44979 45000 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123

MRA $324.00 $434.00 $622.00 $247.00 $296.00 $250.00 $28.00 $815.00 $1,041.00 $1,027.00 $1,132.00 $994.00 $741.00 $1,277.00 $1,581.00 $1,036.00 $1,076.00 $1,050.00 $1,326.00 $1,049.00 $1,115.00 $161.00 $268.00 $393.00 BR $791.00 $755.00 $708.00 BR $644.00 $643.00 $136.00 $790.00 $631.00 BR $329.00 $197.00 $364.00 $321.00 $419.00 $1,801.00 $1,270.00 $1,904.00 $1,885.00 $1,732.00 $1,485.00 $1,911.00 $1,845.00 $1,870.00 $1,126.00

FUD 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 0 0 0 90 90 90 YYY 90 90 ZZZ 90 90 YYY 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 96


Surgery CPT Code 45126 45130 45135 45136 45150 45160 45171 45172 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45340 45341 45342 45346 45347 45349 45350 45379 45380 45381 45382 45384 45385 45386 45388 45389 45390 45391 45392 45393 45395 45397

MRA $2,444.00 $1,041.00 $1,354.00 $1,526.00 $475.00 $949.00 $615.00 $835.00 $623.00 $75.00 $72.00 $102.00 $172.00 $137.00 $174.00 $211.00 $209.00 $230.00 $154.00 $96.00 $87.00 $120.00 $174.00 $176.00 $171.00 $144.00 $144.00 $212.00 $328.00 $153.00 $224.00 $3,167.00 $168.00 $214.00 $593.00 $415.00 $369.00 $388.00 $481.00 $415.00 $479.00 $739.00 $3,327.00 $311.00 $355.00 $283.00 $358.00 $271.00 $1,813.00 $1,969.00

FUD 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90

Surgery CPT Code 45398 45400 45402 45500 45505 45520 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45900 45905 45910 45915 45990 45999 46020 46030 46040 46045 46050 46060 46080 46083 46200 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 46288 46320 46500 46505 46600

MRA $744.00 $1,058.00 $1,435.00 $584.00 $510.00 $46.00 $1,009.00 $888.00 $1,350.00 $618.00 $915.00 $1,412.00 $1,050.00 $1,273.00 $1,066.00 $1,241.00 $120.00 $133.00 $163.00 $142.00 $105.00 BR $230.00 $94.00 $393.00 $312.00 $105.00 $482.00 $246.00 $98.00 $323.00 $118.00 $124.00 $198.00 $400.00 $501.00 $504.00 $539.00 $598.00 $655.00 $686.00 $328.00 $442.00 $514.00 $335.00 $521.00 $126.00 $109.00 $229.00 $38.00

FUD 0 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 10 10 10 10 0 YYY 10 10 90 90 10 90 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 0


Surgery CPT Code 46601 46604 46606 46607 46608 46610 46611 46612 46614 46615 46700 46706 46707 46710 46712 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46930 46940 46942 46945 46946 46947 46999 47000 47001 47010 47015 47100 47120 47122

MRA $140.00 $92.00 $66.00 $195.00 $115.00 $114.00 $149.00 $196.00 $169.00 $202.00 $585.00 $140.00 $473.00 $953.00 $1,999.00 $545.00 $906.00 $1,584.00 $1,881.00 $1,671.00 $2,236.00 $2,412.00 $2,725.00 $2,933.00 $636.00 $511.00 $188.00 $846.00 $813.00 $731.00 $128.00 $144.00 $145.00 $228.00 $189.00 $297.00 $207.00 $165.00 $145.00 $199.00 $270.00 $328.00 BR $218.00 $141.00 $788.00 $755.00 $550.00 $1,663.00 $2,512.00

FUD 0 0 0 0 0 0 0 0 0 0 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 10 10 10 10 10 90 10 10 90 90 90 YYY 0 ZZZ 90 90 90 90 90

Part A, 97


Surgery CPT Code 47125 47130 47135 47146 47147 47300 47350 47360 47361 47362 47370 47371 47379 47380 47381 47382 47383 47399 47400 47420 47425 47460 47480 47490 47531 47532 47533 47534 47535 47536 47537 47538 47539 47540 47541 47542 47543 47544 47550 47552 47553 47554 47555 47556 47562 47563 47564 47570 47579 47600

MRA $2,293.00 $2,482.00 $6,164.00 $337.00 $393.00 $778.00 $942.00 $1,305.00 $2,129.00 $849.00 $943.00 $889.00 BR $1,107.00 $1,094.00 $660.00 $7,678.00 BR $1,435.00 $1,222.00 $1,275.00 $1,039.00 $755.00 $467.00 $379.00 $835.00 $1,362.00 $1,678.00 $1,126.00 $831.00 $411.00 $4,584.00 $5,009.00 $5,208.00 $1,202.00 $526.00 $1,350.00 $831.00 $209.00 $364.00 $342.00 $594.00 $383.00 $425.00 $837.00 $900.00 $1,069.00 $961.00 BR $868.00

FUD 90 90 90 0 0 90 90 90 90 90 90 90 YYY 90 90 10 10 YYY 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ ZZZ 0 0 0 0 0 90 90 90 90 YYY 90

Surgery CPT Code 47605 47610 47612 47620 47700 47701 47711 47712 47715 47720 47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900 47999 48000 48001 48020 48100 48102 48105 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48400 48500 48510 48520 48540 48545 48547 48548 48552 48554 48556

MRA $935.00 $1,164.00 $1,276.00 $1,295.00 $1,111.00 $1,913.00 $1,442.00 $1,793.00 $1,157.00 $1,040.00 $1,248.00 $1,188.00 $1,425.00 $1,568.00 $1,624.00 $1,635.00 $1,871.00 $1,485.00 $906.00 $1,352.00 $1,331.00 BR $1,053.00 $1,305.00 $983.00 $779.00 $341.00 $2,505.00 $1,083.00 $1,546.00 $1,661.00 $1,830.00 $1,149.00 $3,101.00 $2,888.00 $3,099.00 $2,893.00 $1,855.00 BR $100.00 $1,012.00 $938.00 $1,103.00 $1,350.00 $1,170.00 $1,630.00 $1,460.00 $230.00 $2,365.00 $1,117.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 90 90 90 90 90 0 90 90


Surgery CPT Code 48999 49000 49002 49010 49020 49040 49060 49062 49082 49083 49084 49180 49185 49203 49204 49205 49215 49220 49250 49255 49320 49321 49322 49323 49324 49325 49326 49327 49329 49400 49402 49405 49406 49407 49411 49412 49418 49419 49421 49422 49423 49424 49425 49426 49427 49428 49429 49435 49436 49440

MRA BR $862.00 $784.00 $915.00 $910.00 $763.00 $827.00 $892.00 $193.00 $300.00 $104.00 $212.00 $1,012.00 $1,049.00 $1,337.00 $1,530.00 $1,551.00 $1,182.00 $622.00 $591.00 $415.00 $443.00 $460.00 $712.00 $348.00 $374.00 $171.00 $133.00 BR $127.00 $748.00 $886.00 $886.00 $749.00 $537.00 $83.00 $1,453.00 $405.00 $452.00 $468.00 $106.00 $54.00 $914.00 $725.00 $48.00 $184.00 $522.00 $110.00 $164.00 $1,113.00

FUD YYY 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 10 10 10 90 10 10 ZZZ ZZZ YYY 0 90 0 0 0 0 ZZZ 0 90 0 10 0 0 90 90 0 10 10 ZZZ 10 10

Part A, 98


Surgery CPT Code 49441 49442 49446 49450 49451 49452 49460 49465 49505 49507 49520 49521 49525 49540 49550 49553 49555 49557 49560 49561 49565 49566 49568 49570 49572 49585 49587 49590 49600 49605 49606 49610 49611 49650 49651 49652 49653 49654 49655 49656 49657 49659 49900 49904 49905 49906 49999 50010 50020 50040

MRA $1,319.00 $1,075.00 $1,100.00 $771.00 $817.00 $998.00 $818.00 $170.00 $510.00 $636.00 $631.00 $730.00 $584.00 $668.00 $557.00 $598.00 $621.00 $715.00 $734.00 $856.00 $754.00 $881.00 $339.00 $411.00 $491.00 $444.00 $501.00 $585.00 $774.00 $1,648.00 $1,416.00 $784.00 $770.00 $484.00 $621.00 $700.00 $874.00 $795.00 $971.00 $864.00 $1,240.00 BR $512.00 $1,394.00 $454.00 BR BR $886.00 $1,084.00 $910.00

FUD 10 10 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 YYY 90 90 90

Surgery CPT Code 50045 50060 50065 50070 50075 50080 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 50230 50234 50236 50240 50250 50280 50290 50320 50327 50328 50329 50340 50360 50365 50370 50380 50382 50384 50385 50386 50387 50389 50390 50391 50395 50396 50400 50405 50430 50431 50432 50433 50434 50435

MRA $1,137.00 $1,394.00 $1,514.00 $1,476.00 $1,839.00 $1,186.00 $1,635.00 $1,250.00 $1,180.00 $1,228.00 $1,301.00 $1,506.00 $151.00 $807.00 $1,316.00 $1,554.00 $1,695.00 $1,671.00 $1,873.00 $1,679.00 $1,157.00 $1,170.00 $1,080.00 $1,680.00 $214.00 $187.00 $179.00 $1,083.00 $2,475.00 $2,941.00 $1,128.00 $1,507.00 $1,594.00 $1,540.00 $1,326.00 $857.00 $772.00 $529.00 $118.00 $139.00 $203.00 $101.00 $1,441.00 $1,802.00 $531.00 $165.00 $860.00 $1,158.00 $916.00 $481.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 90 90 0 0 0 0 0 0


Surgery CPT Code 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50549 50551 50553 50555 50557 50561 50562 50570 50572 50574 50575 50576 50580 50590 50592 50593 50600 50605 50606 50610 50620 50630 50650 50660 50684 50686 50688 50690 50693 50694 50695 50700 50705 50706 50715 50722 50725

MRA $1,471.00 $1,281.00 $1,644.00 $1,639.00 $1,468.00 $1,037.00 $1,093.00 $1,374.00 $1,428.00 $1,273.00 $1,325.00 $1,702.00 $1,555.00 BR $411.00 $447.00 $668.00 $676.00 $755.00 $580.00 $549.00 $728.00 $762.00 $991.00 $801.00 $726.00 $980.00 $5,936.00 $4,692.00 $1,150.00 $1,054.00 $538.00 $1,209.00 $1,152.00 $1,170.00 $1,297.00 $1,426.00 $74.00 $109.00 $89.00 $85.00 $1,078.00 $1,187.00 $1,447.00 $1,192.00 $1,735.00 $778.00 $1,397.00 $1,211.00 $1,371.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 90 0 0 0 0 0 0 90 10 10 90 90 ZZZ 90 90 90 90 90 0 0 10 0 0 0 0 90 ZZZ ZZZ 90 90 90

Part A, 99


Surgery CPT Code 50727 50728 50740 50750 50760 50770 50780 50782 50783 50785 50800 50810 50815 50820 50825 50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 50949 50951 50953 50955 50957 50961 50970 50972 50974 50976 50980 51020 51030 51040 51045 51050 51060 51065 51080 51100 51101 51102 51500 51520

MRA $640.00 $924.00 $1,386.00 $1,457.00 $1,389.00 $1,485.00 $1,391.00 $1,465.00 $1,515.00 $1,548.00 $1,226.00 $1,527.00 $1,643.00 $1,729.00 $2,351.00 $2,292.00 $1,493.00 $1,513.00 $1,163.00 $1,043.00 $1,075.00 $1,380.00 $1,107.00 $1,096.00 $1,384.00 $1,265.00 BR $414.00 $461.00 $546.00 $546.00 $510.00 $510.00 $408.00 $661.00 $641.00 $443.00 $587.00 $538.00 $439.00 $548.00 $596.00 $768.00 $704.00 $510.00 $63.00 $130.00 $335.00 $775.00 $764.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 0 0 0 90 90

Surgery CPT Code 51525 51530 51535 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700 51701 51702 51703 51705 51710 51715 51720 51725 51725-26 51725-TC 51726 51726-26 51726-TC 51727 51727-26 51727-TC 51728 51728-26 51728-TC 51729 51729-26 51729-TC 51736 51736-26 51736-TC 51741 51741-26 51741-TC 51784 51784-26 51784-TC 51785

MRA $1,069.00 $957.00 $932.00 $1,171.00 $1,514.00 $1,624.00 $1,762.00 $2,284.00 $2,252.00 $2,601.00 $2,441.00 $2,900.00 $3,063.00 $2,914.00 $54.00 $83.00 $45.00 $29.00 $58.00 $92.00 $128.00 $37.00 $119.00 $322.00 $140.00 $116.00 $79.00 $199.00 $136.00 $90.00 $274.00 $314.00 $111.00 $203.00 $315.00 $108.00 $207.00 $341.00 $131.00 $211.00 $47.00 $32.00 $15.00 $81.00 $59.00 $17.00 $119.00 $80.00 $136.00 $52.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0


Surgery CPT Code 51785-26 51785-TC 51792 51792-26 51792-TC 51797 51797-26 51797-TC 51798 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52001 52005 52007 52010 52204 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281 52282 52283 52285 52287 52290 52300

MRA $80.00 $155.00 $143.00 $60.00 $213.00 $109.00 $84.00 $205.00 $20.00 $1,294.00 $1,236.00 $858.00 $1,040.00 $843.00 $912.00 $1,150.00 $590.00 $1,050.00 $881.00 $1,167.00 $2,082.00 $1,848.00 $858.00 $850.00 $925.00 $190.00 $133.00 $265.00 $230.00 $292.00 $286.00 $367.00 $339.00 $471.00 $546.00 $887.00 $311.00 $262.00 $243.00 $374.00 $446.00 $490.00 $448.00 $259.00 $560.00 $309.00 $375.00 $311.00 $304.00 $370.00

FUD 0 0 0 0 0 ZZZ ZZZ ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Part A, 100


Surgery CPT Code MRA 52301 $382.00 52305 $370.00 52310 $348.00 52315 $553.00 52317 $772.00 52318 $684.00 52320 $369.00 52325 $494.00 52327 $369.00 52330 $507.00 52332 $451.00 52334 $340.00 52341 $317.00 52342 $344.00 52343 $380.00 52344 $407.00 52345 $433.00 52346 $488.00 52351 $297.00 52352 $349.00 52353 $404.00 52354 $372.00 52355 $447.00 52356 $424.00 52400 $580.00 52402 $279.00 52441 $1,258.00 52442 $962.00 52450 $602.00 52500 $705.00 52601 $1,021.00 52630 $653.00 52640 $573.00 52647 $858.00 52648 $957.00 52649 $973.00 52700 $517.00 53000 $224.00 53010 $336.00 53020 $153.00 53040 $460.00 53060 $180.00 53080 $567.00 53085 $836.00 53200 $218.00 53210 $904.00 53215 $1,142.00 53220 $546.00 53230 $760.00 53235 $607.00

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 10 90 0 90 10 90 90 0 90 90 90 90 90

Surgery CPT Code 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53448 53449 53450 53460 53500 53502 53505 53510 53515 53520 53600 53601 53605 53620 53621 53660 53661 53665 53850 53852 53855 53860 53899 54015 54050 54055 54056 54057 54060 54065

MRA $506.00 $464.00 $240.00 $295.00 $226.00 $332.00 $929.00 $1,088.00 $1,151.00 $1,381.00 $1,088.00 $1,150.00 $1,116.00 $1,053.00 $1,057.00 $639.00 $755.00 $1,197.00 $699.00 $991.00 $1,259.00 $784.00 $447.00 $494.00 $719.00 $590.00 $586.00 $777.00 $987.00 $661.00 $37.00 $37.00 $81.00 $59.00 $45.00 $49.00 $50.00 $50.00 $741.00 $728.00 $770.00 $1,546.00 BR $348.00 $91.00 $106.00 $100.00 $149.00 $180.00 $281.00

FUD 90 90 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 0 90 YYY 10 10 10 10 10 10 10


Surgery CPT Code 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54240-26 54240-TC 54250 54250-26 54250-TC 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 54332 54336 54340 54344 54348 54352 54360 54380 54385 54390 54400 54401 54405 54406 54408

MRA $149.00 $261.00 $775.00 $1,035.00 $1,210.00 $588.00 $777.00 $1,092.00 $1,532.00 $1,945.00 $220.00 $207.00 $182.00 $78.00 $633.00 $189.00 $104.00 $172.00 $81.00 $109.00 $68.00 $24.00 $104.00 $116.00 $9.00 $830.00 $988.00 $881.00 $1,067.00 $1,316.00 $900.00 $974.00 $1,260.00 $1,212.00 $1,201.00 $1,327.00 $1,672.00 $727.00 $1,360.00 $1,318.00 $1,820.00 $898.00 $1,054.00 $1,217.00 $1,635.00 $784.00 $892.00 $1,294.00 $687.00 $724.00

FUD 0 10 90 90 90 90 90 90 90 90 10 10 10 10 90 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 101


Surgery CPT Code MRA 54410 $856.00 54411 $933.00 54415 $510.00 54416 $665.00 54417 $819.00 54420 $899.00 54430 $799.00 54435 $503.00 54437 $701.00 54438 $1,413.00 54440 BR 54450 $88.00 54500 $102.00 54505 $259.00 54512 $519.00 54520 $445.00 54522 $589.00 54530 $683.00 54535 $922.00 54550 $588.00 54560 $842.00 54600 $524.00 54620 $373.00 54640 $594.00 54650 $861.00 54660 $401.00 54670 $485.00 54680 $948.00 54690 $825.00 54692 $850.00 54699 BR 54700 $133.00 54800 $257.00 54830 $411.00 54840 $432.00 54860 $503.00 54861 $696.00 54865 $333.00 54900 $969.00 54901 $1,340.00 55000 $109.00 55040 $439.00 55041 $634.00 55060 $430.00 55100 $156.00 55110 $223.00 55120 $350.00 55150 $562.00 55175 $426.00 55180 $796.00

FUD 90 90 90 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 10 0 90 90 90 90 90 90 90 0 90 90 90 10 90 90 90 90 90

Surgery CPT Code 55200 55250 55300 55400 55450 55500 55520 55530 55535 55540 55550 55559 55600 55605 55650 55680 55700 55705 55706 55720 55725 55801 55810 55812 55815 55821 55831 55840 55842 55845 55860 55862 55865 55866 55870 55873 55875 55876 55899 55920 56405 56420 56440 56441 56442 56501 56515 56605 56606 56620

MRA $310.00 $349.00 $167.00 $660.00 $391.00 $445.00 $446.00 $467.00 $496.00 $572.00 $486.00 BR $486.00 $609.00 $853.00 $426.00 $183.00 $368.00 $373.00 $555.00 $670.00 $1,331.00 $1,711.00 $1,989.00 $2,328.00 $1,153.00 $1,252.00 $1,705.00 $1,859.00 $2,222.00 $1,012.00 $1,351.00 $1,890.00 $1,615.00 $166.00 $1,127.00 $729.00 $147.00 BR $420.00 $131.00 $130.00 $271.00 $183.00 $45.00 $122.00 $200.00 $96.00 $49.00 $607.00

FUD 90 90 0 90 10 90 90 90 90 90 90 YYY 90 90 90 90 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 0 YYY 0 10 10 10 10 0 10 10 0 ZZZ 90


Surgery CPT Code 56625 56630 56631 56632 56633 56634 56637 56640 56700 56740 56800 56805 56810 56820 56821 57000 57010 57020 57022 57023 57061 57065 57100 57105 57106 57107 57109 57110 57111 57112 57120 57130 57135 57150 57155 57156 57160 57170 57180 57200 57210 57220 57230 57240 57250 57260 57265 57267 57268 57270

MRA $735.00 $1,061.00 $1,400.00 $1,636.00 $1,350.00 $1,537.00 $1,806.00 $1,777.00 $227.00 $321.00 $310.00 $1,349.00 $316.00 $119.00 $154.00 $237.00 $429.00 $118.00 $179.00 $290.00 $124.00 $251.00 $90.00 $132.00 $409.00 $1,467.00 $1,787.00 $1,015.00 $1,793.00 $1,907.00 $612.00 $220.00 $231.00 $50.00 $383.00 $198.00 $67.00 $74.00 $124.00 $313.00 $395.00 $378.00 $442.00 $536.00 $485.00 $700.00 $902.00 $284.00 $577.00 $867.00

FUD 90 90 90 90 90 90 90 90 10 10 10 90 10 0 0 10 90 0 10 10 10 10 0 10 90 90 90 90 90 90 90 10 10 0 0 0 0 0 10 90 90 90 90 90 90 90 90 ZZZ 90 90

Part A, 102


Surgery CPT Code MRA 57280 $1,071.00 57282 $734.00 57283 $673.00 57284 $950.00 57285 $607.00 57287 $685.00 57288 $1,009.00 57289 $879.00 57291 $622.00 57292 $925.00 57295 $485.00 57296 $880.00 57300 $653.00 57305 $995.00 57307 $997.00 57308 $769.00 57310 $517.00 57311 $612.00 57320 $693.00 57330 $916.00 57335 $963.00 57400 $70.00 57410 $57.00 57415 $75.00 57420 $124.00 57421 $162.00 57423 $848.00 57425 $902.00 57426 $879.00 57452 $96.00 57454 $125.00 57455 $149.00 57456 $141.00 57460 $223.00 57461 $333.00 57500 $89.00 57505 $105.00 57510 $140.00 57511 $159.00 57513 $191.00 57520 $359.00 57522 $319.00 57530 $386.00 57531 $2,036.00 57540 $815.00 57545 $700.00 57550 $486.00 57555 $774.00 57556 $718.00 57558 $120.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 0 0 90 90 90 0 0 0 0 0 0 0 10 10 10 10 90 90 90 90 90 90 90 90 90 10

Surgery CPT Code 57700 57720 57800 58100 58110 58120 58140 58145 58146 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58301 58321 58322 58323 58340 58345 58346 58350 58353 58356 58400 58410 58520 58540 58541 58542 58543 58544 58545 58546 58548 58550

MRA $279.00 $328.00 $71.00 $74.00 $53.00 $297.00 $1,010.00 $677.00 $1,089.00 $1,110.00 $1,159.00 $1,118.00 $1,562.00 $2,080.00 $2,898.00 $926.00 $1,026.00 $1,120.00 $1,133.00 $1,019.00 $1,121.00 $1,132.00 $1,360.00 $1,089.00 $1,197.00 $1,268.00 $1,318.00 $1,168.00 $71.00 $81.00 $90.00 $24.00 $87.00 $335.00 $408.00 $103.00 $225.00 $531.00 $519.00 $752.00 $663.00 $923.00 $793.00 $877.00 $891.00 $965.00 $876.00 $1,104.00 $1,688.00 $1,038.00

FUD 90 90 0 0 ZZZ 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 58552 58553 58554 58555 58558 58559 58560 58561 58562 58563 58565 58570 58571 58572 58573 58578 58579 58600 58605 58611 58615 58660 58661 58662 58670 58671 58672 58673 58679 58700 58720 58740 58750 58752 58760 58770 58800 58805 58820 58822 58825 58900 58920 58925 58940 58943 58950 58951 58952 58953

MRA $853.00 $1,096.00 $1,085.00 $261.00 $340.00 $436.00 $482.00 $677.00 $339.00 $450.00 $2,189.00 $844.00 $922.00 $1,047.00 $1,178.00 BR BR $337.00 $298.00 $47.00 $319.00 $793.00 $804.00 $807.00 $450.00 $463.00 $872.00 $928.00 BR $544.00 $844.00 $508.00 $949.00 $893.00 $769.00 $763.00 $343.00 $509.00 $326.00 $603.00 $469.00 $489.00 $571.00 $820.00 $592.00 $1,368.00 $1,170.00 $1,703.00 $1,876.00 $1,839.00

FUD 90 90 90 0 0 0 0 0 0 0 90 90 90 90 90 YYY YYY 90 90 ZZZ 10 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Part A, 103


Surgery CPT Code 58954 58956 58957 58958 58960 58999 59000 59001 59012 59015 59020 59020-26 59020-TC 59025 59025-26 59025-TC 59030 59050 59051 59100 59120 59121 59130 59135 59136 59140 59150 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618

MRA $1,999.00 $1,329.00 $1,365.00 $1,511.00 $1,174.00 BR $123.00 $167.00 $267.00 $168.00 $85.00 $40.00 $23.00 $54.00 $32.00 $10.00 $155.00 $71.00 $47.00 $633.00 $893.00 $768.00 $832.00 $1,083.00 $934.00 $461.00 $543.00 $690.00 $279.00 $79.00 $179.00 $196.00 $316.00 $375.00 $1,816.00 $1,019.00 $1,123.00 $141.00 $134.00 $414.00 $708.00 $140.00 $2,064.00 $1,199.00 $1,324.00 $591.00 $1,805.00 $1,113.00 $1,208.00 $2,035.00

FUD 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 0

Surgery CPT Code 59620 59622 59812 59820 59821 59830 59840 59841 59850 59851 59852 59855 59856 59857 59866 59870 59871 59898 59899 60000 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60300 60500 60502 60505 60512 60520 60521 60522 60540 60545 60600 60605 60650 60659 60699 61020

MRA $1,293.00 $1,397.00 $343.00 $389.00 $398.00 $496.00 $331.00 $443.00 $449.00 $464.00 $642.00 $477.00 $577.00 $711.00 $304.00 $348.00 $192.00 BR BR $114.00 $96.00 $744.00 $872.00 $1,170.00 $851.00 $1,107.00 $1,228.00 $1,427.00 $1,911.00 $1,022.00 $1,468.00 $1,210.00 $546.00 $670.00 $99.00 $1,232.00 $1,475.00 $1,631.00 $310.00 $1,405.00 $1,591.00 $1,820.00 $1,272.00 $1,505.00 $1,477.00 $1,624.00 $1,340.00 BR BR $150.00

FUD 0 0 90 90 90 90 10 10 90 90 90 90 90 90 0 90 0 YYY YYY 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 90 90 90 90 90 YYY YYY 0


Surgery CPT Code 61026 61050 61055 61070 61105 61107 61108 61120 61140 61150 61151 61154 61156 61210 61215 61250 61253 61304 61305 61312 61313 61314 61315 61316 61320 61321 61322 61323 61330 61332 61333 61340 61343 61345 61450 61458 61460 61480 61500 61501 61510 61512 61514 61516 61517 61518 61519 61520 61521 61522

MRA $138.00 $106.00 $143.00 $67.00 $503.00 $863.00 $959.00 $733.00 $1,389.00 $1,503.00 $795.00 $1,393.00 $1,473.00 $527.00 $637.00 $888.00 $1,042.00 $2,005.00 $2,419.00 $2,187.00 $2,207.00 $2,200.00 $2,393.00 $88.00 $2,118.00 $2,310.00 $1,779.00 $1,842.00 $1,706.00 $2,307.00 $2,231.00 $1,584.00 $2,673.00 $2,259.00 $2,173.00 $2,433.00 $2,426.00 $1,922.00 $1,637.00 $1,353.00 $2,506.00 $2,981.00 $2,262.00 $2,253.00 $74.00 $3,163.00 $3,450.00 $4,349.00 $3,667.00 $2,415.00

FUD 0 0 0 0 90 0 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90

Part A, 104


Surgery CPT Code 61524 61526 61530 61531 61533 61534 61535 61536 61537 61538 61539 61540 61541 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 61559 61563 61564 61566 61567 61570 61571 61575 61576 61580 61581 61582 61583 61584 61585 61586 61590 61591 61592 61595 61596 61597 61598 61600 61601 61605 61606

MRA $2,484.00 $3,918.00 $3,611.00 $1,344.00 $1,712.00 $1,535.00 $958.00 $2,862.00 $1,714.00 $2,466.00 $2,660.00 $2,069.00 $2,363.00 $2,307.00 $2,271.00 $3,474.00 $2,695.00 $1,964.00 $1,141.00 $1,463.00 $1,760.00 $1,807.00 $2,085.00 $2,700.00 $2,175.00 $2,597.00 $2,048.00 $2,340.00 $1,975.00 $2,140.00 $2,992.00 $3,772.00 $2,383.00 $2,674.00 $2,557.00 $2,972.00 $2,830.00 $3,142.00 $2,097.00 $3,299.00 $3,491.00 $3,245.00 $2,350.00 $2,827.00 $3,046.00 $2,693.00 $2,039.00 $2,279.00 $2,299.00 $3,178.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

Surgery CPT Code 61607 61608 61610 61611 61612 61613 61615 61616 61618 61619 61623 61624 61626 61630 61635 61640 61641 61642 61645 61650 61651 61680 61682 61684 61686 61690 61692 61697 61698 61700 61702 61703 61705 61708 61710 61711 61720 61735 61750 61751 61760 61770 61781 61782 61783 61790 61791 61796 61797 61798

MRA $2,961.00 $3,458.00 $2,354.00 $584.00 $2,219.00 $3,375.00 $2,576.00 $3,535.00 $1,389.00 $1,682.00 $540.00 $1,073.00 $877.00 $1,245.00 $1,362.00 $555.00 $195.00 $390.00 $809.00 $540.00 $229.00 $2,758.00 $4,798.00 $3,341.00 $5,012.00 $2,556.00 $4,007.00 $3,231.00 $3,103.00 $4,037.00 $4,019.00 $1,444.00 $3,043.00 $2,546.00 $2,129.00 $3,150.00 $1,558.00 $1,664.00 $1,521.00 $1,628.00 $1,670.00 $1,867.00 $240.00 $197.00 $241.00 $952.00 $1,205.00 $1,027.00 $224.00 $1,404.00

FUD 90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 ZZZ 90


Surgery CPT Code 61799 61800 61850 61860 61863 61864 61867 61868 61870 61880 61885 61886 61888 62000 62005 62010 62100 62115 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62148 62160 62161 62162 62163 62164 62165 62180 62190 62192 62194 62200 62201 62220 62223 62225 62230 62252 62252-26 62252-TC 62256 62258

MRA $308.00 $156.00 $1,090.00 $1,197.00 $1,231.00 $295.00 $1,863.00 $491.00 $616.00 $559.00 $262.00 $678.00 $331.00 $848.00 $1,282.00 $1,754.00 $1,962.00 $1,686.00 $2,211.00 $1,898.00 $1,822.00 $1,221.00 $1,955.00 $1,011.00 $1,096.00 $1,566.00 $1,327.00 $1,566.00 $120.00 $172.00 $1,229.00 $1,578.00 $999.00 $1,706.00 $1,336.00 $1,695.00 $1,034.00 $1,146.00 $239.00 $1,625.00 $1,200.00 $1,215.00 $1,199.00 $488.00 $935.00 $85.00 $49.00 $42.00 $616.00 $1,308.00

FUD ZZZ ZZZ 90 90 90 ZZZ 90 ZZZ 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 0 0 90 90

Part A, 105


Surgery CPT Code 62263 62264 62267 62268 62269 62270 62272 62273 62280 62281 62282 62284 62287 62290 62291 62292 62294 62302 62303 62304 62305 62310 62311 62318 62319 62350 62351 62355 62360 62361 62362 62365 62367 62368 62369 62370 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 63040 63042 63043

MRA $426.00 $593.00 $253.00 $285.00 $271.00 $109.00 $137.00 $130.00 $199.00 $186.00 $211.00 $196.00 $784.00 $235.00 $232.00 $1,064.00 $821.00 $246.00 $256.00 $244.00 $266.00 $200.00 $201.00 $208.00 $203.00 $488.00 $782.00 $402.00 $195.00 $390.00 $517.00 $418.00 $39.00 $53.00 $121.00 $128.00 $1,882.00 $1,591.00 $1,390.00 $1,151.00 $1,568.00 $1,862.00 $1,788.00 $1,489.00 $1,395.00 $1,145.00 $280.00 $1,764.00 $1,620.00 BR

FUD 10 10 0 0 0 0 0 0 10 10 10 0 90 0 0 90 90 0 0 0 0 0 0 0 0 10 90 10 10 10 10 10 0 0 0 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 ZZZ

Surgery CPT Code 63044 63045 63046 63047 63048 63050 63051 63055 63056 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102 63103 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 63267 63268 63270

MRA BR $1,647.00 $2,117.00 $1,907.00 $367.00 $1,411.00 $1,605.00 $2,029.00 $1,960.00 $421.00 $2,200.00 $263.00 $1,720.00 $383.00 $1,828.00 $261.00 $2,203.00 $391.00 $2,416.00 $282.00 $2,930.00 $381.00 $2,490.00 $249.00 $2,127.00 $2,127.00 $249.00 $1,788.00 $1,672.00 $1,851.00 $1,486.00 $1,711.00 $1,347.00 $1,610.00 $1,444.00 $1,593.00 $1,603.00 $1,810.00 $1,725.00 $1,956.00 $2,258.00 $1,569.00 $3,182.00 $3,207.00 $3,319.00 $1,940.00 $2,053.00 $1,651.00 $1,469.00 $2,197.00

FUD ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63295 63300 63301 63302 63303 63304 63305 63306 63307 63308 63600 63610 63615 63620 63621 63650 63655 63661 63662 63663 63664 63685 63688 63700 63702 63704 63706 63707 63709 63710 63740 63741 63744 63746 64400

MRA $2,401.00 $2,206.00 $2,012.00 $2,166.00 $2,135.00 $1,905.00 $1,877.00 $2,529.00 $2,496.00 $2,305.00 $2,041.00 $2,934.00 $3,003.00 $3,012.00 $3,073.00 $319.00 $2,006.00 $2,209.00 $2,290.00 $2,357.00 $2,513.00 $2,574.00 $2,596.00 $2,522.00 $425.00 $797.00 $476.00 $1,348.00 $1,133.00 $256.00 $819.00 $1,064.00 $584.00 $792.00 $811.00 $820.00 $615.00 $707.00 $1,340.00 $1,512.00 $1,708.00 $1,873.00 $1,041.00 $1,310.00 $1,165.00 $1,062.00 $741.00 $738.00 $529.00 $78.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 0 90 90 ZZZ 10 90 10 90 10 90 10 10 90 90 90 90 90 90 90 90 90 90 90 0

Part A, 106


Surgery CPT Code 64402 64405 64408 64410 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449 64450 64455 64461 64462 64463 64479 64480 64483 64484 64486 64487 64488 64489 64490 64491 64492 64493 64494 64495 64505 64508 64510 64517 64520 64530 64550 64553 64555 64561 64565 64566

MRA $75.00 $103.00 $120.00 $109.00 $128.00 $109.00 $159.00 $105.00 $108.00 $89.00 $128.00 $116.00 $130.00 $114.00 $68.00 $165.00 $77.00 $152.00 $152.00 $53.00 $49.00 $151.00 $86.00 $164.00 $224.00 $194.00 $206.00 $183.00 $127.00 $156.00 $156.00 $218.00 $196.00 $96.00 $97.00 $177.00 $88.00 $89.00 $104.00 $99.00 $103.00 $188.00 $131.00 $135.00 $23.00 $137.00 $131.00 $801.00 $121.00 $121.00

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 ZZZ 0 ZZZ 0 0 0 0 0 ZZZ ZZZ 0 ZZZ ZZZ 0 0 0 0 0 0 0 10 10 10 10 0

Surgery CPT Code 64568 64569 64570 64575 64580 64581 64585 64590 64595 64600 64605 64610 64611 64612 64615 64616 64617 64620 64630 64632 64633 64634 64635 64636 64640 64642 64643 64644 64645 64646 64647 64650 64653 64680 64681 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721 64722 64726 64727 64732 64734

MRA $628.00 $799.00 $709.00 $367.00 $343.00 $745.00 $37.00 $217.00 $153.00 $228.00 $319.00 $307.00 $114.00 $188.00 $146.00 $125.00 $193.00 $185.00 $202.00 $87.00 $441.00 $200.00 $435.00 $181.00 $208.00 $142.00 $93.00 $162.00 $114.00 $152.00 $176.00 $62.00 $71.00 $180.00 $464.00 $383.00 $402.00 $562.00 $678.00 $867.00 $715.00 $523.00 $558.00 $446.00 $439.00 $411.00 $271.00 $261.00 $405.00 $432.00

FUD 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 ZZZ 10 ZZZ 10 0 ZZZ 0 ZZZ 0 0 0 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90


Surgery CPT Code 64736 64738 64740 64742 64744 64746 64755 64760 64763 64766 64771 64772 64774 64776 64778 64782 64783 64784 64786 64787 64788 64790 64792 64795 64802 64804 64809 64818 64820 64821 64822 64823 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64872

MRA $388.00 $475.00 $461.00 $517.00 $798.00 $494.00 $1,042.00 $578.00 $561.00 $713.00 $632.00 $636.00 $392.00 $390.00 $249.00 $482.00 $298.00 $751.00 $1,281.00 $458.00 $381.00 $884.00 $1,148.00 $247.00 $711.00 $1,202.00 $1,080.00 $845.00 $838.00 $609.00 $609.00 $703.00 $592.00 $171.00 $711.00 $834.00 $856.00 $480.00 $1,058.00 $1,063.00 $1,137.00 $1,313.00 $341.00 $1,524.00 $1,798.00 $970.00 $1,250.00 $1,238.00 $1,162.00 $155.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 90 ZZZ

Part A, 107


Surgery CPT Code 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64910 64911 64999 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 65275 65280 65285 65286 65290 65400

MRA $230.00 $189.00 $1,382.00 $1,636.00 $1,112.00 $1,243.00 $1,177.00 $1,321.00 $1,500.00 $1,185.00 $1,419.00 $1,549.00 $865.00 $982.00 $1,059.00 $1,472.00 $645.00 $783.00 BR $678.00 $712.00 $726.00 $769.00 $846.00 $1,305.00 $1,386.00 $1,456.00 $312.00 $730.00 $678.00 $738.00 $652.00 $862.00 $654.00 $45.00 $53.00 $58.00 $62.00 $627.00 $956.00 $1,104.00 $88.00 $223.00 $376.00 $75.00 $711.00 $1,177.00 $692.00 $519.00 $603.00

FUD ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 10 90 90 90 90 90 90 90 90

Surgery CPT Code 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65756 65770 65772 65775 65778 65779 65780 65781 65782 65785 65800 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66170 66172 66174 66175 66179 66180 66183 66184

MRA $142.00 $448.00 $534.00 $81.00 $88.00 $319.00 $52.00 $325.00 $1,124.00 $1,314.00 $1,381.00 $1,373.00 $1,201.00 $1,461.00 $449.00 $595.00 $1,389.00 $1,238.00 $766.00 $1,169.00 $1,008.00 $2,144.00 $88.00 $516.00 $327.00 $813.00 $968.00 $441.00 $339.00 $540.00 $572.00 $597.00 $641.00 $945.00 $752.00 $700.00 $164.00 $160.00 $631.00 $798.00 $795.00 $942.00 $1,089.00 $1,264.00 $1,006.00 $1,140.00 $1,092.00 $1,313.00 $1,090.00 $796.00

FUD 0 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 0 90 90 90 90 10 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90


Surgery CPT Code 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 66840 66850 66852 66920 66930 66940 66982 66983 66984 66985 66986 66990 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036 67039 67040 67041

MRA $769.00 $711.00 $1,006.00 $602.00 $359.00 $359.00 $825.00 $1,136.00 $543.00 $623.00 $595.00 $526.00 $627.00 $506.00 $513.00 $507.00 $506.00 $473.00 $506.00 $433.00 $483.00 $433.00 $275.00 $753.00 $651.00 $707.00 $805.00 $878.00 $785.00 $906.00 $819.00 $846.00 $763.00 $898.00 $744.00 $1,038.00 $84.00 BR $639.00 $647.00 $637.00 $774.00 $1,089.00 $338.00 $485.00 $402.00 $1,384.00 $1,490.00 $1,960.00 $1,065.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ YYY 90 90 90 90 90 0 90 90 90 90 90 90

Part A, 108


Surgery CPT Code 67042 67043 67101 67105 67107 67108 67110 67113 67115 67120 67121 67141 67145 67208 67210 67218 67220 67221 67225 67227 67228 67229 67250 67255 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67346 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445

MRA $1,218.00 $1,279.00 $767.00 $941.00 $1,350.00 $1,878.00 $1,040.00 $1,405.00 $496.00 $751.00 $962.00 $536.00 $514.00 $655.00 $779.00 $1,217.00 $894.00 $325.00 $44.00 $652.00 $1,025.00 $926.00 $793.00 $872.00 BR $616.00 $773.00 $688.00 $857.00 $663.00 $602.00 $560.00 $621.00 $447.00 $253.00 $559.00 $628.00 $275.00 $173.00 BR $960.00 $799.00 $976.00 $909.00 $1,023.00 $146.00 $1,729.00 $1,203.00 $1,257.00 $1,269.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 10 10 90 90 90 YYY 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 10 0 YYY 90 90 90 90 90 0 90 90 90 90

Surgery CPT Code MRA 67450 $1,300.00 67500 $75.00 67505 $109.00 67515 $53.00 67550 $946.00 67560 $936.00 67570 $1,148.00 67599 BR 67700 $87.00 67710 $117.00 67715 $102.00 67800 $119.00 67801 $189.00 67805 $208.00 67808 $308.00 67810 $133.00 67820 $36.00 67825 $130.00 67830 $239.00 67835 $500.00 67840 $187.00 67850 $143.00 67875 $163.00 67880 $442.00 67882 $643.00 67900 $487.00 67901 $646.00 67902 $650.00 67903 $657.00 67904 $720.00 67906 $633.00 67908 $550.00 67909 $577.00 67911 $517.00 67912 $983.00 67914 $487.00 67915 $252.00 67916 $675.00 67917 $631.00 67921 $419.00 67922 $243.00 67923 $718.00 67924 $605.00 67930 $280.00 67935 $520.00 67938 $67.00 67950 $584.00 67961 $571.00 67966 $645.00 67971 $875.00

FUD 90 0 0 0 90 90 90 YYY 10 10 10 10 10 10 90 0 0 10 10 90 10 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 10 90 90 90 90


Surgery CPT Code MRA 67973 $1,126.00 67974 $1,140.00 67975 $681.00 67999 BR 68020 $106.00 68040 $75.00 68100 $137.00 68110 $172.00 68115 $248.00 68130 $378.00 68135 $146.00 68200 $59.00 68320 $502.00 68325 $672.00 68326 $654.00 68328 $741.00 68330 $488.00 68335 $636.00 68340 $413.00 68360 $449.00 68362 $691.00 68371 $363.00 68399 BR 68400 $154.00 68420 $191.00 68440 $96.00 68500 $882.00 68505 $921.00 68510 $491.00 68520 $687.00 68525 $340.00 68530 $379.00 68540 $875.00 68550 $1,107.00 68700 $628.00 68705 $176.00 68720 $807.00 68745 $704.00 68750 $792.00 68760 $109.00 68761 $130.00 68770 $634.00 68801 $202.00 68810 $290.00 68811 $191.00 68815 $399.00 68816 $592.00 68840 $100.00 68850 $76.00 68899 BR

FUD 90 90 90 YYY 10 0 0 10 10 90 10 0 90 90 90 90 90 90 90 90 90 10 YYY 10 10 10 90 90 0 90 0 10 90 90 90 10 90 90 90 10 10 90 10 10 10 10 10 10 0 YYY

Part A, 109


Surgery CPT Code 69000 69005 69020 69100 69105 69110 69120 69140 69145 69150 69155 69200 69205 69209 69210 69220 69222 69300 69310 69320 69399 69420 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 69632 69633 69635 69636

MRA $52.00 $175.00 $109.00 $85.00 $87.00 $294.00 $274.00 $722.00 $248.00 $1,111.00 $1,680.00 $53.00 $110.00 $13.00 $39.00 $78.00 $123.00 $522.00 $937.00 $1,434.00 BR $117.00 $155.00 $84.00 $145.00 $182.00 $699.00 $525.00 $829.00 $1,118.00 $1,176.00 $1,221.00 $1,616.00 $2,824.00 $126.00 $998.00 $1,621.00 $2,600.00 $1,195.00 $1,225.00 $1,264.00 $1,263.00 $1,526.00 $41.00 $651.00 $985.00 $1,166.00 $1,110.00 $1,207.00 $1,381.00

FUD 10 10 10 0 0 90 90 90 90 90 90 0 10 0 0 0 10 YYY 90 90 YYY 10 10 0 10 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90

Surgery CPT Code 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69710 69711 69714 69715 69717 69718 69720 69725 69740 69745 69799 69801 69805 69806 69820 69840 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 69990 G0127 G0168 G0247 G0289 G0341 G0342 G0343

MRA $1,370.00 $1,154.00 $1,519.00 $1,389.00 $1,529.00 $1,479.00 $1,620.00 $879.00 $1,072.00 $1,412.00 $1,386.00 $887.00 $887.00 $988.00 $828.00 $702.00 BR $878.00 $961.00 $1,217.00 $996.00 $1,232.00 $1,307.00 $1,922.00 $1,274.00 $1,447.00 BR $785.00 $1,187.00 $1,123.00 $876.00 $869.00 $1,013.00 $1,228.00 $1,754.00 $1,498.00 BR $2,017.00 $2,185.00 $2,116.00 $2,306.00 BR $262.00 $17.00 $75.00 $38.00 $82.00 $333.00 $622.00 $1,026.00

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90 90 YYY 90 90 90 90 YYY ZZZ 0 0 ZZZ ZZZ 0 90 90


Surgery CPT Code MRA G0364 $12.00 G0412 $742.00 G0413 $1,092.00 G0414 $1,017.00 G0415 $1,407.00 G0429 $102.00

FUD ZZZ 90 90 90 90 0

Part A, 110


Radiology CPT Code 70010 70010-26 70010-TC 70015 70015-26 70015-TC 70030 70030-26 70030-TC 70100 70100-26 70100-TC 70110 70110-26 70110-TC 70120 70120-26 70120-TC 70130 70130-26 70130-TC 70134 70134-26 70134-TC 70140 70140-26 70140-TC 70150 70150-26 70150-TC 70160 70160-26 70160-TC 70170 70170-26 70170-TC 70190 70190-26 70190-TC 70200 70200-26 70200-TC 70210 70210-26 70210-TC 70220 70220-26 70220-TC 70240 70240-26

MRA $70.00 $19.00 $51.00 $58.00 $31.00 $27.00 $24.00 $10.00 $15.00 $29.00 $9.00 $19.00 $36.00 $12.00 $22.00 $32.00 $9.00 $22.00 $46.00 $17.00 $29.00 $45.00 $17.00 $28.00 $33.00 $9.00 $22.00 $42.00 $12.00 $29.00 $29.00 $8.00 $19.00 $52.00 $15.00 $37.00 $34.00 $10.00 $22.00 $43.00 $14.00 $29.00 $32.00 $8.00 $22.00 $42.00 $12.00 $29.00 $26.00 $9.00

Radiology CPT Code 70240-TC 70250 70250-26 70250-TC 70260 70260-26 70260-TC 70300 70300-26 70300-TC 70310 70310-26 70310-TC 70320 70320-26 70320-TC 70328 70328-26 70328-TC 70330 70330-26 70330-TC 70332 70332-26 70332-TC 70336 70336-26 70336-TC 70350 70350-26 70350-TC 70355 70355-26 70355-TC 70360 70360-26 70360-TC 70370 70370-26 70370-TC 70371 70371-26 70371-TC 70380 70380-26 70380-TC 70390 70390-26 70390-TC 70450

MRA $15.00 $35.00 $12.00 $22.00 $50.00 $17.00 $33.00 $15.00 $5.00 $10.00 $24.00 $8.00 $15.00 $40.00 $11.00 $29.00 $28.00 $10.00 $18.00 $43.00 $12.00 $31.00 $107.00 $27.00 $80.00 $497.00 $72.00 $419.00 $24.00 $10.00 $14.00 $32.00 $10.00 $21.00 $24.00 $8.00 $15.00 $65.00 $16.00 $48.00 $122.00 $43.00 $79.00 $34.00 $8.00 $24.00 $87.00 $19.00 $68.00 $221.00


Radiology CPT Code 70450-26 70450-TC 70460 70460-26 70460-TC 70470 70470-26 70470-TC 70480 70480-26 70480-TC 70481 70481-26 70481-TC 70482 70482-26 70482-TC 70486 70486-26 70486-TC 70487 70487-26 70487-TC 70488 70488-26 70488-TC 70490 70490-26 70490-TC 70491 70491-26 70491-TC 70492 70492-26 70492-TC 70496 70496-26 70496-TC 70498 70498-26 70498-TC 70540 70540-26 70540-TC 70542 70542-26 70542-TC 70543 70543-26 70543-TC

MRA $43.00 $176.00 $271.00 $58.00 $211.00 $332.00 $65.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $236.00 $58.00 $176.00 $279.00 $66.00 $211.00 $339.00 $72.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $366.00 $92.00 $270.00 $366.00 $92.00 $270.00 $482.00 $70.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00

Part A, 111



MRA $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $497.00 $76.00 $419.00 $596.00 $91.00 $502.00 $1,055.00 $120.00 $931.00 $618.00 $99.00 $520.00 BR $118.00 BR $392.00 $148.00 $349.00 $425.00 $164.00 $376.00 $548.00 $164.00 $499.00 $27.00 $9.00 $17.00 $30.00 $10.00 $19.00 $35.00 $11.00


MRA $22.00 $41.00 $13.00 $28.00 $44.00 $16.00 $28.00 $49.00 $19.00 $29.00 $45.00 $16.00 $29.00 $79.00 $23.00 $54.00 $56.00 $19.00 $38.00 $33.00 $11.00 $21.00 $38.00 $13.00 $24.00 $43.00 $13.00 $29.00 $49.00 $16.00 $33.00 $35.00 $10.00 $24.00 $38.00 $11.00 $26.00 $282.00 $59.00 $220.00 $328.00 $63.00 $264.00 $402.00 $70.00 $330.00 $431.00 $100.00 $328.00 $490.00



MRA $75.00 $415.00 $587.00 $88.00 $496.00 $1,029.00 $114.00 $911.00 $514.00 $92.00 $419.00 $22.00 $7.00 $15.00 $34.00 $11.00 $22.00 $49.00 $16.00 $33.00 $61.00 $18.00 $42.00 $36.00 $11.00 $24.00 $39.00 $11.00 $28.00 $45.00 $11.00 $34.00 $36.00 $11.00 $24.00 $39.00 $14.00 $25.00 $63.00 $16.00 $46.00 $68.00 $18.00 $50.00 $81.00 $21.00 $61.00 $36.00 $11.00 $24.00

Part A, 112



MRA $50.00 $16.00 $34.00 $64.00 $18.00 $44.00 $45.00 $11.00 $33.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $391.00 $65.00 $323.00 $503.00 $82.00 $419.00 $604.00 $99.00 $502.00 $549.00 $82.00 $465.00 $603.00 $98.00 $502.00 $543.00 $76.00


MRA $465.00 $597.00 $92.00 $502.00 $1,066.00 $131.00 $931.00 $1,066.00 $131.00 $931.00 $1,056.00 $121.00 $931.00 $563.00 $94.00 $465.00 $29.00 $8.00 $19.00 $35.00 $10.00 $24.00 $413.00 $94.00 $315.00 $278.00 $56.00 $220.00 $317.00 $59.00 $256.00 $380.00 $62.00 $317.00 $491.00 $74.00 $415.00 $526.00 $84.00 $442.00 $1,037.00 $114.00 $919.00 $517.00 $95.00 $419.00 $29.00 $9.00 $19.00 $33.00



MRA $9.00 $22.00 $30.00 $8.00 $21.00 $132.00 $26.00 $106.00 $129.00 $28.00 $101.00 $132.00 $28.00 $104.00 $176.00 $39.00 $137.00 $112.00 $34.00 $78.00 $101.00 $15.00 $86.00 $107.00 $13.00 $94.00 $28.00 $8.00 $19.00 $29.00 $8.00 $19.00 $26.00 $7.00 $17.00 $31.00 $9.00 $21.00 $68.00 $17.00 $51.00 $35.00 $10.00 $24.00 $30.00 $8.00 $21.00 $27.00 $7.00 $19.00

Part A, 113



MRA $30.00 $8.00 $21.00 $74.00 $19.00 $55.00 $28.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $54.00 $17.00 $37.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $59.00 $220.00 $342.00 $63.00 $277.00 $375.00 $94.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00


MRA $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $513.00 $92.00 $419.00 $30.00 $10.00 $20.00 $42.00 $11.00 $30.00 $52.00 $15.00 $37.00 $40.00 $12.00 $28.00 $49.00 $15.00 $34.00 $57.00 $16.00 $40.00 $84.00 $21.00 $63.00 $28.00 $9.00 $19.00 $33.00 $10.00 $23.00 $29.00 $8.00 $19.00 $31.00 $9.00 $21.00 $35.00 $11.00 $22.00 $28.00 $8.00 $18.00 $84.00



MRA $18.00 $66.00 $29.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $72.00 $19.00 $53.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $26.00 $8.00 $17.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $61.00 $220.00 $341.00 $62.00 $277.00 $379.00 $98.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00

Part A, 114



MRA $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $515.00 $92.00 $419.00 $29.00 $9.00 $19.00 $33.00 $11.00 $21.00 $37.00 $13.00 $22.00 $44.00 $16.00 $28.00 $274.00 $60.00 $211.00 $322.00 $65.00 $256.00 $390.00 $71.00 $317.00 $502.00 $112.00 $390.00 $418.00 $98.00 $315.00 $219.00 $89.00 $130.00 $327.00 $93.00 $235.00 $381.00 $102.00 $279.00 $498.00 $85.00 $415.00 $587.00 $88.00


MRA $496.00 $1,037.00 $114.00 $919.00 $514.00 $92.00 $419.00 $73.00 $24.00 $49.00 $63.00 $18.00 $44.00 $68.00 $23.00 $44.00 $77.00 $27.00 $48.00 $160.00 $60.00 $100.00 $91.00 $35.00 $55.00 $91.00 $35.00 $56.00 $137.00 $46.00 $89.00 $97.00 $35.00 $61.00 $99.00 $35.00 $63.00 $144.00 $46.00 $96.00 $73.00 $23.00 $48.00 $85.00 $34.00 $48.00 $82.00 $25.00 $56.00 $248.00



MRA $122.00 $126.00 $376.00 $127.00 $249.00 $757.00 $117.00 $639.00 $100.00 $35.00 $64.00 $136.00 $50.00 $84.00 $201.00 $103.00 $95.00 $44.00 $16.00 $28.00 $31.00 $19.00 $104.00 $107.00 $11.00 $104.00 $155.00 $35.00 $120.00 $155.00 $35.00 $120.00 $165.00 $45.00 $120.00 $121.00 $26.00 $95.00 $137.00 $38.00 $99.00 $145.00 $27.00 $118.00 $274.00 $44.00 $230.00 $89.00 $24.00 $63.00

Part A, 115



MRA $98.00 $24.00 $72.00 $105.00 $24.00 $79.00 $117.00 $18.00 $97.00 $68.00 $18.00 $50.00 $48.00 $14.00 $34.00 $62.00 $19.00 $43.00 $101.00 $57.00 $44.00 $60.00 $14.00 $46.00 $75.00 $16.00 $59.00 $74.00 $27.00 $47.00 $146.00 $27.00 $119.00 $57.00 $17.00 $39.00 $426.00 $154.00 $273.00 $233.00 $91.00 $142.00 $68.00 $19.00 $49.00 $150.00 $30.00 $120.00 $88.00 $32.00


MRA $55.00 $462.00 $79.00 $344.00 $495.00 $99.00 $344.00 $656.00 $87.00 $525.00 $683.00 $101.00 $526.00 $56.00 $13.00 $44.00 $50.00 $28.00 $22.00 $291.00 $87.00 $204.00 $349.00 $126.00 $222.00 $341.00 $119.00 $222.00 $497.00 $25.00 $472.00 $183.00 $20.00 $163.00 $143.00 $15.00 $128.00 $239.00 $37.00 $202.00 $445.00 $75.00 $370.00 $540.00 $66.00 $474.00 $587.00 $109.00 $478.00 $194.00



MRA $21.00 $173.00 $293.00 $35.00 $258.00 $530.00 $56.00 $474.00 $530.00 $56.00 $474.00 $540.00 $65.00 $475.00 $530.00 $56.00 $474.00 $540.00 $65.00 $475.00 $253.00 $37.00 $216.00 $530.00 $56.00 $474.00 $183.00 $20.00 $163.00 $80.00 $3.00 $77.00 $331.00 $83.00 $248.00 $245.00 $41.00 $204.00 $264.00 $58.00 $206.00 $271.00 $40.00 $231.00 $289.00 $58.00 $231.00 $54.00 $24.00 $30.00

Part A, 116



MRA $530.00 $56.00 $474.00 $72.00 $35.00 $37.00 $111.00 $54.00 $57.00 $194.00 $21.00 $173.00 $530.00 $56.00 $474.00 $54.00 $6.00 $48.00 $549.00 $74.00 $475.00 $531.00 $57.00 $474.00 $549.00 $73.00 $476.00 $531.00 $57.00 $474.00 $531.00 $57.00 $474.00 $530.00 $56.00 $474.00 $72.00 $35.00 $37.00 $546.00 $71.00 $475.00 $546.00 $71.00 $475.00 $530.00 $56.00 $474.00 $530.00 $56.00


MRA $474.00 $499.00 $26.00 $473.00 $972.00 $65.00 $907.00 $124.00 $84.00 $39.00 $98.00 $23.00 $75.00 $93.00 $19.00 $74.00 BR $254.00 BR BR $98.00 BR BR $132.00 BR BR $394.00 BR BR $338.00 BR BR $225.00 BR BR $197.00 BR $618.00 $27.00 $591.00 $333.00 $18.00 $315.00 $659.00 $66.00 $593.00 $333.00 $18.00 $315.00 $475.00


Radiology CPT Code 75970-26 75970-TC 75978 75978-26 75978-TC 75984 75984-26 75984-TC 75989 75989-26 75989-TC 76000 76000-26 76000-TC 76001 76001-26 76001-TC 76080 76080-26 76080-TC 76098 76098-26 76098-TC 76100 76100-26 76100-TC 76101 76101-26 76101-TC 76102 76102-26 76102-TC 76120 76120-26 76120-TC 76125 76125-26 76125-TC 76140 76376 76376-26 76376-TC 76377 76377-26 76377-TC 76380 76380-26 76380-TC 76390 76390-26

MRA $42.00 $433.00 $617.00 $26.00 $591.00 $110.00 $36.00 $74.00 $180.00 $59.00 $121.00 $58.00 $8.00 $48.00 $134.00 $34.00 $97.00 $67.00 $27.00 $40.00 $23.00 $8.00 $15.00 $77.00 $30.00 $46.00 $94.00 $36.00 $59.00 $95.00 $30.00 $65.00 $157.00 $56.00 $102.00 $49.00 $17.00 $33.00 $31.00 $144.00 $11.00 $133.00 $185.00 $43.00 $142.00 $182.00 $50.00 $131.00 $493.00 $71.00

Part A, 117



MRA $419.00 BR BR $79.00 BR BR $94.00 BR BR $280.00 BR BR BR $88.00 $33.00 $53.00 $171.00 $86.00 $85.00 $96.00 $48.00 $48.00 $96.00 $36.00 $60.00 $96.00 $36.00 $60.00 $12.00 $10.00 $3.00 $99.00 $37.00 $63.00 $88.00 $31.00 $53.00 $86.00 $31.00 $53.00 $83.00 $31.00 $54.00 $78.00 $28.00 $48.00 $109.00 $37.00 $72.00 $90.00


MRA $35.00 $55.00 $116.00 $42.00 $73.00 $84.00 $30.00 $53.00 $112.00 $38.00 $73.00 $84.00 $30.00 $53.00 $124.00 $36.00 $88.00 $112.00 $61.00 $54.00 $93.00 $51.00 $42.00 $73.00 $43.00 $30.00 $131.00 $51.00 $79.00 $252.00 $100.00 $151.00 $243.00 $100.00 $142.00 $145.00 $94.00 $51.00 $125.00 $55.00 $71.00 $83.00 $46.00 $37.00 $88.00 $33.00 $53.00 $72.00 $30.00 $41.00



MRA $96.00 $39.00 $57.00 $105.00 $40.00 $60.00 $101.00 $40.00 $60.00 $93.00 $27.00 $66.00 $103.00 $38.00 $66.00 $160.00 $65.00 $73.00 $71.00 $46.00 $27.00 $97.00 $35.00 $65.00 $72.00 $29.00 $42.00 $93.00 $35.00 $57.00 $95.00 $37.00 $57.00 $93.00 $35.00 $57.00 $59.00 $19.00 $39.00 $90.00 $33.00 $57.00 $93.00 $36.00 $57.00 $151.00 $68.00 $80.00 $120.00 $32.00

Part A, 118



MRA $88.00 $36.00 $25.00 $11.00 $93.00 $34.00 $59.00 $93.00 $34.00 $59.00 $341.00 $102.00 $236.00 $34.00 $17.00 $18.00 $171.00 $104.00 $68.00 $128.00 $69.00 $59.00 $92.00 $24.00 $68.00 $93.00 $34.00 $59.00 $78.00 $19.00 $59.00 $77.00 $19.00 $58.00 $281.00 $84.00 $208.00 $60.00 $20.00 $39.00 $99.00 $41.00 $58.00 $34.00 $3.00 $31.00 BR $61.00 $96.00 BR

Radiology CPT Code 76999-26 76999-TC 77001 77001-26 77001-TC 77002 77002-26 77002-TC 77003 77003-26 77003-TC 77011 77011-26 77011-TC 77012 77012-26 77012-TC 77013-26 77013-TC 77014 77014-26 77014-TC 77021 77021-26 77021-TC 77022 77022-26 77022-TC 77051 77051-26 77051-TC 77052 77052-26 77052-TC 77053 77053-26 77053-TC 77054 77054-26 77054-TC 77055 77055-26 77055-TC 77056 77056-26 77056-TC 77057 77057-26 77057-TC 77058

MRA BR BR $83.00 $18.00 $64.00 $75.00 $25.00 $50.00 $73.00 $27.00 $45.00 $309.00 $58.00 $251.00 $306.00 $55.00 $251.00 $191.00 $297.00 $135.00 $41.00 $94.00 $353.00 $73.00 $280.00 BR $204.00 $280.00 $17.00 $3.00 $14.00 $17.00 $3.00 $14.00 $102.00 $17.00 $85.00 $126.00 $22.00 $104.00 $78.00 $33.00 $45.00 $97.00 $41.00 $56.00 $82.00 $33.00 $49.00 $804.00


Radiology CPT Code 77058-26 77058-TC 77059 77059-26 77059-TC 77063 77063-26 77063-TC 77071 77072 77072-26 77072-TC 77073 77073-26 77073-TC 77074 77074-26 77074-TC 77075 77075-26 77075-TC 77077 77077-26 77077-TC 77078 77078-26 77078-TC 77080 77080-26 77080-TC 77081 77081-26 77081-TC 77084 77084-26 77084-TC 77085 77085-26 77085-TC 77086 77086-26 77086-TC 77261 77262 77263 77280 77280-26 77280-TC 77285 77285-26

MRA $78.00 $726.00 $994.00 $78.00 $917.00 $56.00 $30.00 $25.00 $29.00 $22.00 $9.00 $14.00 $42.00 $13.00 $29.00 $64.00 $22.00 $42.00 $89.00 $26.00 $63.00 $54.00 $15.00 $39.00 $84.00 $12.00 $72.00 $83.00 $11.00 $72.00 $40.00 $11.00 $29.00 $356.00 $77.00 $280.00 $57.00 $16.00 $41.00 $36.00 $9.00 $27.00 $73.00 $110.00 $163.00 $166.00 $36.00 $130.00 $264.00 $53.00

Part A, 119



MRA $209.00 $325.00 $79.00 $243.00 $432.00 $104.00 $328.00 $1,287.00 $232.00 $1,046.00 BR BR BR $87.00 $36.00 $52.00 $1,473.00 $415.00 $1,046.00 $151.00 $73.00 $78.00 $292.00 $151.00 $140.00 $191.00 $73.00 $117.00 $248.00 $96.00 $153.00 $358.00 $151.00 $207.00 $200.00 $48.00 $150.00 $64.00 $45.00 $18.00 $78.00 $27.00 $50.00 $115.00 $43.00 $70.00 $187.00 $63.00 $121.00 $111.00

Radiology CPT Code 77338 77338-26 77338-TC 77370 77371 77372 77373 77399 77399-26 77399-TC 77401 77402 77407 77412 77417 77422 77423 77427 77431 77432 77435 77469 77470 77470-26 77470-TC 77499 77499-26 77499-TC 77520 77522 77523 77525 77600 77600-26 77600-TC 77605 77605-26 77605-TC 77610 77610-26 77610-TC 77615 77615-26 77615-TC 77620 77620-26 77620-TC 77750 77750-26 77750-TC

MRA $502.00 $223.00 $279.00 $130.00 $1,151.00 $874.00 $1,630.00 BR BR BR $66.00 $66.00 $78.00 $87.00 $21.00 $70.00 $91.00 $166.00 $95.00 $417.00 $644.00 $313.00 $527.00 $106.00 $417.00 BR BR BR BR BR BR BR $196.00 $80.00 $113.00 $263.00 $108.00 $151.00 $195.00 $79.00 $113.00 $262.00 $106.00 $151.00 $196.00 $80.00 $113.00 $299.00 $248.00 $49.00



MRA $284.00 $188.00 $93.00 $427.00 $289.00 $135.00 $605.00 $435.00 $167.00 $227.00 $55.00 $172.00 $356.00 $73.00 $283.00 $324.00 $102.00 $222.00 $604.00 $199.00 $405.00 $922.00 $282.00 $640.00 $764.00 $568.00 $192.00 $74.00 $57.00 $16.00 $72.00 $53.00 $18.00 BR BR BR $78.00 $9.00 $69.00 $198.00 $18.00 $179.00 $240.00 $25.00 $215.00 $132.00 $34.00 $96.00 $173.00 $42.00

Part A, 120



MRA $130.00 $248.00 $44.00 $202.00 $35.00 $30.00 $5.00 $112.00 $36.00 $68.00 $357.00 $59.00 $298.00 $446.00 $80.00 $366.00 $242.00 $38.00 $202.00 BR BR BR $106.00 $28.00 $77.00 $158.00 $39.00 $118.00 $194.00 $41.00 $152.00 $45.00 $9.00 $35.00 $108.00 $11.00 $96.00 $78.00 $11.00 $65.00 $125.00 $16.00 $108.00 $196.00 $22.00 $171.00 $139.00 $32.00 $106.00 $216.00


MRA $33.00 $182.00 $179.00 $31.00 $147.00 $110.00 $20.00 $88.00 $272.00 $57.00 $214.00 $307.00 $31.00 $274.00 $216.00 $49.00 $152.00 BR BR BR $112.00 $22.00 $88.00 $135.00 $26.00 $108.00 $259.00 $36.00 $220.00 $265.00 $46.00 $214.00 $135.00 $24.00 $109.00 $160.00 $29.00 $130.00 $339.00 $37.00 $301.00 $418.00 $45.00 $373.00 $106.00 $23.00 $82.00 $146.00 $27.00 $118.00


Radiology CPT Code 78232 78232-26 78232-TC 78258 78258-26 78258-TC 78261 78261-26 78261-TC 78262 78262-26 78262-TC 78264 78264-26 78264-TC 78265 78265-26 78265-TC 78266 78266-26 78266-TC 78267 78268 78270 78270-26 78270-TC 78271 78271-26 78271-TC 78272 78272-26 78272-TC 78278 78278-26 78278-TC 78282 78282-26 78282-TC 78290 78290-26 78290-TC 78291 78291-26 78291-TC 78299 78299-26 78299-TC 78300 78300-26 78300-TC

MRA $157.00 $23.00 $132.00 $146.00 $38.00 $108.00 $190.00 $36.00 $152.00 $195.00 $35.00 $159.00 $195.00 $40.00 $154.00 $381.00 $49.00 $332.00 $494.00 $54.00 $440.00 BR BR $68.00 $10.00 $58.00 $72.00 $10.00 $61.00 $100.00 $14.00 $87.00 $234.00 $50.00 $182.00 $230.00 $19.00 $224.00 $149.00 $35.00 $113.00 $161.00 $45.00 $114.00 BR BR BR $125.00 $32.00 $93.00

Part A, 121


Radiology CPT Code 78305 78305-26 78305-TC 78306 78306-26 78306-TC 78315 78315-26 78315-TC 78320 78320-26 78320-TC 78350 78350-26 78350-TC 78351 78399 78399-26 78399-TC 78414 78414-26 78414-TC 78428 78428-26 78428-TC 78445 78445-26 78445-TC 78451 78451-26 78451-TC 78452 78452-26 78452-TC 78453 78453-26 78453-TC 78454 78454-26 78454-TC 78456 78456-26 78456-TC 78457 78457-26 78457-TC 78458 78458-26 78458-TC 78459

MRA $181.00 $42.00 $137.00 $205.00 $44.00 $159.00 $233.00 $52.00 $179.00 $276.00 $53.00 $220.00 $40.00 $11.00 $29.00 $23.00 BR BR BR BR $23.00 BR $126.00 $41.00 $84.00 $97.00 $28.00 $69.00 $351.00 $68.00 $283.00 $486.00 $80.00 $407.00 $313.00 $51.00 $263.00 $446.00 $67.00 $379.00 $205.00 $49.00 $151.00 $140.00 $39.00 $99.00 $198.00 $46.00 $149.00 $755.00


MRA $100.00 $731.00 $135.00 $36.00 $97.00 $180.00 $41.00 $137.00 $244.00 $47.00 $195.00 $259.00 $50.00 $206.00 $387.00 $75.00 $308.00 $248.00 $51.00 $195.00 $373.00 $77.00 $294.00 $756.00 $85.00 $731.00 $764.00 $100.00 $731.00 $324.00 $59.00 $262.00 $92.00 $24.00 $66.00 BR BR BR $191.00 $24.00 $166.00 $167.00 $38.00 $128.00 $343.00 $53.00 $289.00 $206.00 $36.00 $171.00



MRA $314.00 $42.00 $272.00 BR BR BR $131.00 $22.00 $108.00 $154.00 $26.00 $126.00 $155.00 $27.00 $126.00 $221.00 $45.00 $177.00 $311.00 $64.00 $245.00 $876.00 $78.00 $855.00 $51.00 $78.00 BR $74.00 $15.00 $59.00 $223.00 $35.00 $188.00 $129.00 $32.00 $95.00 $158.00 $29.00 $128.00 $268.00 $46.00 $220.00 $206.00 $31.00 $173.00 $107.00 $27.00 $79.00 BR BR

Part A, 122



MRA BR $137.00 $22.00 $113.00 $158.00 $24.00 $133.00 $217.00 $49.00 $166.00 $231.00 $61.00 $166.00 $241.00 $68.00 $166.00 $256.00 $34.00 $220.00 $87.00 $19.00 $66.00 $73.00 $18.00 $55.00 $109.00 $29.00 $79.00 $157.00 $36.00 $119.00 BR BR BR $162.00 $34.00 $126.00 $199.00 $40.00 $158.00 $252.00 $44.00 $207.00 $303.00 $56.00 $245.00 $227.00 $55.00 $171.00 $166.00

Radiology CPT Code 78805-26 78805-TC 78806 78806-26 78806-TC 78807 78807-26 78807-TC 78808 78811 78811-26 78811-TC 78812 78812-26 78812-TC 78813 78813-26 78813-TC 78814 78814-26 78814-TC 78815 78815-26 78815-TC 78816 78816-26 78816-TC 78999 78999-26 78999-TC 79005 79005-26 79005-TC 79101 79101-26 79101-TC 79200 79200-26 79200-TC 79300 79300-26 79300-TC 79403 79403-26 79403-TC 79440 79440-26 79440-TC 79445 79445-26

MRA $38.00 $126.00 $286.00 $44.00 $241.00 $303.00 $57.00 $245.00 $47.00 $879.00 $83.00 $855.00 $884.00 $102.00 $855.00 $885.00 $106.00 $855.00 $982.00 $116.00 $950.00 $985.00 $128.00 $950.00 $986.00 $132.00 $950.00 BR BR BR $199.00 $94.00 $105.00 $207.00 $103.00 $105.00 $203.00 $102.00 $97.00 BR $83.00 BR $287.00 $121.00 $165.00 $204.00 $104.00 $97.00 $232.00 $127.00


Radiology CPT Code 79445-TC 79999 79999-26 79999-TC G0130 G0130-26 G0130-TC G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0252-26 G0278 G0279 G0279-26 G0279-TC G0288 G0297 G0297-26 G0297-TC G0365 G0365-26 G0365-TC G0389 G0389-26 G0389-TC G6001 G6001-26 G6001-TC G6002 G6002-26 G6002-TC G6003 G6004 G6005 G6006 G6007 G6008 G6009 G6010 G6011 G6012 G6013 G6014 G6015

MRA $105.00 BR BR BR $34.00 $10.00 $24.00 $120.00 $32.00 $88.00 $136.00 $40.00 $96.00 $109.00 $32.00 $77.00 $78.00 $13.00 $56.00 $30.00 $25.00 $201.00 $255.00 $52.00 $203.00 $164.00 $12.00 $152.00 $104.00 $27.00 $77.00 $52.00 $30.00 $22.00 $76.00 $20.00 $55.00 $188.00 $146.00 $145.00 $145.00 $303.00 $202.00 $199.00 $199.00 $324.00 $266.00 $266.00 $266.00 $347.00

Part A, 123


Radiology CPT Code G6016 Q0092

MRA $346.00 $14.00


Part A, 124


Pathology & Laboratory CPT Code MRA 80048 $23.00 80048-26 $4.00 80048-TC $19.00 80050 $45.00 80050-26 $18.00 80050-TC $26.00 80051 $16.00 80051-26 $6.00 80051-TC $10.00 80053 $29.00 80053-26 $8.00 80053-TC $21.00 80055 $67.00 80055-26 $21.00 80055-TC $43.00 80061 $31.00 80061-26 $11.00 80061-TC $19.00 80069 $26.00 80069-26 $6.00 80069-TC $20.00 80074 $107.00 80074-26 $43.00 80074-TC $64.00 80076 $18.00 80076-26 $7.00 80076-TC $11.00 80150 $40.00 80150-26 $13.00 80150-TC $26.00 80156 $35.00 80156-26 $11.00 80156-TC $23.00 80157 $22.00 80157-26 $8.00 80157-TC $14.00 80158 $35.00 80158-26 $12.00 80158-TC $22.00 80162 $13.00 80162-26 $3.00 80162-TC $9.00 80164 $43.00 80164-26 $14.00 80164-TC $29.00 80168 $43.00 80168-26 $17.00 80168-TC $25.00 80170 $18.00 80170-26 $6.00

Pathology & Laboratory CPT Code MRA 80170-TC $11.00 80173 $33.00 80173-26 $11.00 80173-TC $22.00 80176 $35.00 80176-26 $11.00 80176-TC $23.00 80178 $17.00 80178-26 $6.00 80178-TC $11.00 80184 $34.00 80184-26 $10.00 80184-TC $23.00 80185 $36.00 80185-26 $10.00 80185-TC $25.00 80186 $38.00 80186-26 $11.00 80186-TC $26.00 80188 $35.00 80188-26 $11.00 80188-TC $23.00 80190 $41.00 80190-26 $13.00 80190-TC $28.00 80192 $44.00 80192-26 $17.00 80192-TC $26.00 80194 $33.00 80194-26 $10.00 80194-TC $22.00 80197 $34.00 80197-26 $11.00 80197-TC $22.00 80198 $20.00 80198-26 $5.00 80198-TC $15.00 80200 $24.00 80200-26 $7.00 80200-TC $16.00 80201 $33.00 80201-26 $11.00 80201-TC $21.00 80202 $42.00 80202-26 $14.00 80202-TC $28.00 80299 BR 80299-26 BR 80299-TC BR 80400 $54.00


Pathology & Laboratory CPT Code MRA 80400-26 $18.00 80400-TC $36.00 80402 $138.00 80402-26 $42.00 80402-TC $95.00 80406 $138.00 80406-26 $42.00 80406-TC $95.00 80408 $213.00 80408-26 $77.00 80408-TC $136.00 80410 $166.00 80410-26 $54.00 80410-TC $110.00 80412 $533.00 80412-26 $176.00 80412-TC $355.00 80414 $88.00 80414-26 $26.00 80414-TC $59.00 80415 $93.00 80415-26 $28.00 80415-TC $64.00 80416 $256.00 80416-26 $88.00 80416-TC $166.00 80417 $256.00 80417-26 $88.00 80417-TC $166.00 80418 $934.00 80418-26 $266.00 80418-TC $666.00 80420 $107.00 80420-26 $33.00 80420-TC $74.00 80422 $62.00 80422-26 $18.00 80422-TC $43.00 80424 $94.00 80424-26 $26.00 80424-TC $67.00 80426 $232.00 80426-26 $54.00 80426-TC $176.00 80428 $93.00 80428-26 $19.00 80428-TC $73.00 80430 $99.00 80430-26 $24.00 80430-TC $74.00

Part A, 125


Pathology & Laboratory CPT Code MRA 80432 $243.00 80432-26 $56.00 80432-TC $186.00 80434 $161.00 80434-26 $49.00 80434-TC $110.00 80435 $166.00 80435-26 $49.00 80435-TC $115.00 80436 $119.00 80436-26 $35.00 80436-TC $85.00 80438 $82.00 80438-26 $24.00 80438-TC $56.00 80439 $176.00 80439-26 $33.00 80439-TC $144.00 80500 $34.00 80500-26 $34.00 80500-TC BR 80502 $72.00 80502-26 $72.00 80502-TC BR 81000 $7.00 81000-26 $3.00 81000-TC $4.00 81001 $7.00 81001-26 $3.00 81001-TC $4.00 81002 $5.00 81002-26 $3.00 81002-TC $3.00 81003 $5.00 81003-26 $2.00 81003-TC $3.00 81005 $3.00 81005-26 $1.00 81005-TC $3.00 81007 $5.00 81007-26 $2.00 81007-TC $4.00 81015 $5.00 81015-26 $3.00 81015-TC $3.00 81020 $8.00 81020-26 $3.00 81020-TC $5.00 81025 $7.00 81025-26 $4.00

Pathology & Laboratory CPT Code MRA 81025-TC $4.00 81050 $33.00 81050-26 $11.00 81050-TC $21.00 81099 BR 81099-26 BR 81099-TC BR 82009 $10.00 82009-26 $3.00 82009-TC $6.00 82010 $22.00 82010-26 $7.00 82010-TC $15.00 82013 $24.00 82013-26 $7.00 82013-TC $17.00 82024 $26.00 82024-26 $7.00 82024-TC $18.00 82030 $43.00 82030-26 $17.00 82030-TC $25.00 82040 $11.00 82040-26 $3.00 82040-TC $7.00 82042 $12.00 82042-26 $3.00 82042-TC $8.00 82043 $14.00 82043-26 $4.00 82043-TC $10.00 82044 $12.00 82044-26 $4.00 82044-TC $9.00 82075 $32.00 82075-26 $10.00 82075-TC $21.00 82085 $24.00 82085-26 $7.00 82085-TC $17.00 82088 $91.00 82088-26 $28.00 82088-TC $62.00 82103 $21.00 82103-26 $7.00 82103-TC $14.00 82104 $22.00 82104-26 $7.00 82104-TC $15.00 82105 $26.00



Part A, 126


Pathology & Laboratory CPT Code MRA 82164 $32.00 82164-26 $10.00 82164-TC $21.00 82172 $33.00 82172-26 $10.00 82172-TC $22.00 82175 $48.00 82175-26 $15.00 82175-TC $33.00 82180 $25.00 82180-26 $8.00 82180-TC $17.00 82190 $24.00 82190-26 $8.00 82190-TC $16.00 82232 $43.00 82232-26 $14.00 82232-TC $29.00 82239 $23.00 82239-26 $8.00 82239-TC $15.00 82240 $49.00 82240-26 $15.00 82240-TC $34.00 82247 $10.00 82247-26 $3.00 82247-TC $7.00 82248 $10.00 82248-26 $3.00 82248-TC $7.00 82252 $11.00 82252-26 $3.00 82252-TC $7.00 82261 $38.00 82261-26 $13.00 82261-TC $24.00 82270 $5.00 82270-26 $2.00 82270-TC $3.00 82274 BR 82274-26 BR 82274-TC BR 82286 $12.00 82286-26 $3.00 82286-TC $8.00 82300 $48.00 82300-26 $15.00 82300-TC $33.00 82306 $79.00 82306-26 $25.00

Pathology & Laboratory CPT Code MRA 82306-TC $52.00 82308 $62.00 82308-26 $18.00 82308-TC $43.00 82310 $11.00 82310-26 $3.00 82310-TC $7.00 82330 $37.00 82330-26 $11.00 82330-TC $25.00 82331 $14.00 82331-26 $4.00 82331-TC $10.00 82340 $13.00 82340-26 $4.00 82340-TC $8.00 82355 $31.00 82355-26 $10.00 82355-TC $20.00 82360 $31.00 82360-26 $10.00 82360-TC $20.00 82365 $31.00 82365-26 $8.00 82365-TC $21.00 82370 $22.00 82370-26 $7.00 82370-TC $15.00 82373 $16.00 82373-26 $5.00 82373-TC $11.00 82374 $10.00 82374-26 $3.00 82374-TC $6.00 82375 $26.00 82375-26 $7.00 82375-TC $18.00 82376 $11.00 82376-26 $3.00 82376-TC $7.00 82378 $31.00 82378-26 $8.00 82378-TC $21.00 82379 $38.00 82379-26 $13.00 82379-TC $24.00 82380 $21.00 82380-26 $6.00 82380-TC $15.00 82382 $38.00



Part A, 127






Part A, 128






Part A, 129





Pathology & Laboratory CPT Code MRA 83721-26 $5.00 83721-TC $11.00 83727 $43.00 83727-26 $14.00 83727-TC $29.00 83735 $15.00 83735-26 $5.00 83735-TC $10.00 83775 $17.00 83775-26 $5.00 83775-TC $12.00 83785 $58.00 83785-26 $17.00 83785-TC $41.00 83789 $39.00 83789-26 $13.00 83789-TC $25.00 83825 $34.00 83825-26 $11.00 83825-TC $22.00 83835 $41.00 83835-26 $12.00 83835-TC $29.00 83857 $26.00 83857-26 $8.00 83857-TC $18.00 83864 $32.00 83864-26 $8.00 83864-TC $22.00 83872 $13.00 83872-26 $4.00 83872-TC $8.00 83873 $54.00 83873-26 $18.00 83873-TC $36.00 83874 $25.00 83874-26 $8.00 83874-TC $17.00 83880 BR 83880-26 BR 83880-TC BR 83883 $11.00 83883-26 $3.00 83883-TC $7.00 83885 $45.00 83885-26 $14.00 83885-TC $32.00 83915 $31.00 83915-26 $10.00 83915-TC $20.00

Part A, 130


Pathology & Laboratory CPT Code MRA 83916 $54.00 83916-26 $18.00 83916-TC $36.00 83918 $41.00 83918-26 $12.00 83918-TC $29.00 83919 $42.00 83919-26 $12.00 83919-TC $29.00 83921 $37.00 83921-26 $12.00 83921-TC $25.00 83930 $11.00 83930-26 $3.00 83930-TC $7.00 83935 $17.00 83935-26 $5.00 83935-TC $12.00 83937 $29.00 83937-26 $10.00 83937-TC $19.00 83945 $32.00 83945-26 $11.00 83945-TC $20.00 83950 BR 83950-26 BR 83950-TC BR 83970 $94.00 83970-26 $31.00 83970-TC $62.00 83986 $8.00 83986-26 $3.00 83986-TC $5.00 83992 $40.00 83992-26 $12.00 83992-TC $28.00 84030 $11.00 84030-26 $3.00 84030-TC $7.00 84035 $12.00 84035-26 $3.00 84035-TC $8.00 84060 $20.00 84060-26 $6.00 84060-TC $14.00 84061 $14.00 84061-26 $4.00 84061-TC $10.00 84066 $18.00 84066-26 $6.00



Pathology & Laboratory CPT Code MRA 84135-26 $19.00 84135-TC $38.00 84138 $56.00 84138-26 $18.00 84138-TC $38.00 84140 $41.00 84140-26 $8.00 84140-TC $33.00 84143 $62.00 84143-26 $20.00 84143-TC $41.00 84144 $38.00 84144-26 $7.00 84144-TC $31.00 84146 $53.00 84146-26 $17.00 84146-TC $36.00 84150 $69.00 84150-26 $20.00 84150-TC $47.00 84152 $42.00 84152-26 $14.00 84152-TC $27.00 84153 $33.00 84153-26 $11.00 84153-TC $21.00 84154 $33.00 84154-26 $11.00 84154-TC $21.00 84155 $12.00 84155-26 $4.00 84155-TC $7.00 84160 $5.00 84160-26 $2.00 84160-TC $2.00 84165 $24.00 84165-26 $8.00 84165-TC $16.00 84166 BR 84166-26 $20.00 84166-TC BR 84181 $29.00 84181-26 $10.00 84181-TC $19.00 84182 $33.00 84182-26 $11.00 84182-TC $21.00 84202 $39.00 84202-26 $13.00 84202-TC $25.00

Part A, 131



Pathology & Laboratory CPT Code MRA 84285-TC $42.00 84295 $10.00 84295-26 $3.00 84295-TC $6.00 84300 $10.00 84300-26 $3.00 84300-TC $6.00 84302 BR 84302-26 BR 84302-TC BR 84305 $34.00 84305-26 $11.00 84305-TC $22.00 84307 $26.00 84307-26 $8.00 84307-TC $18.00 84311 $11.00 84311-26 $3.00 84311-TC $7.00 84315 $5.00 84315-26 $2.00 84315-TC $3.00 84375 $37.00 84375-26 $11.00 84375-TC $25.00 84376 $10.00 84376-26 $3.00 84376-TC $7.00 84377 $10.00 84377-26 $3.00 84377-TC $7.00 84378 $25.00 84378-26 $8.00 84378-TC $17.00 84379 $25.00 84379-26 $8.00 84379-TC $17.00 84392 $8.00 84392-26 $2.00 84392-TC $6.00 84402 $72.00 84402-26 $21.00 84402-TC $49.00 84403 $67.00 84403-26 $19.00 84403-TC $45.00 84425 $54.00 84425-26 $17.00 84425-TC $37.00 84430 $31.00



Part A, 132



Pathology & Laboratory CPT Code MRA 84583-TC $7.00 84585 $36.00 84585-26 $11.00 84585-TC $24.00 84586 $42.00 84586-26 $14.00 84586-TC $27.00 84588 $73.00 84588-26 $23.00 84588-TC $47.00 84590 $33.00 84590-26 $11.00 84590-TC $21.00 84591 $26.00 84591-26 $9.00 84591-TC $18.00 84597 $37.00 84597-26 $11.00 84597-TC $25.00 84600 $43.00 84600-26 $13.00 84600-TC $31.00 84620 $29.00 84620-26 $8.00 84620-TC $20.00 84630 $26.00 84630-26 $8.00 84630-TC $18.00 84681 $52.00 84681-26 $17.00 84681-TC $35.00 84702 $38.00 84702-26 $11.00 84702-TC $26.00 84703 $22.00 84703-26 $6.00 84703-TC $15.00 84830 $17.00 84830-26 $5.00 84830-TC $12.00 84999 BR 84999-26 BR 84999-TC BR 85002 $10.00 85002-26 $3.00 85002-TC $6.00 85004 BR 85004-26 BR 85004-TC BR 85007 $6.00


Pathology & Laboratory CPT Code MRA 85007-26 $3.00 85007-TC $4.00 85008 $5.00 85008-26 $2.00 85008-TC $3.00 85009 $8.00 85009-26 $3.00 85009-TC $5.00 85013 $3.00 85013-26 $1.00 85013-TC $2.00 85014 $4.00 85014-26 $1.00 85014-TC $3.00 85018 $5.00 85018-26 $2.00 85018-TC $3.00 85025 $20.00 85025-26 $6.00 85025-TC $14.00 85027 $15.00 85027-26 $5.00 85027-TC $10.00 85032 BR 85032-26 BR 85032-TC BR 85041 $7.00 85041-26 $3.00 85041-TC $4.00 85044 $10.00 85044-26 $3.00 85044-TC $6.00 85045 $6.00 85045-26 $2.00 85045-TC $4.00 85046 $13.00 85046-26 $4.00 85046-TC $9.00 85048 $7.00 85048-26 $3.00 85048-TC $4.00 85049 BR 85049-26 BR 85049-TC BR 85060 $25.00 85060-26 $7.00 85060-TC $18.00 85097 $59.00 85097-26 $59.00 85097-TC BR

Part A, 133





Pathology & Laboratory CPT Code MRA 85366-26 $3.00 85366-TC $10.00 85370 $20.00 85370-26 $5.00 85370-TC $15.00 85378 $13.00 85378-26 $4.00 85378-TC $8.00 85379 $18.00 85379-26 $6.00 85379-TC $12.00 85380 BR 85380-26 BR 85380-TC BR 85384 $11.00 85384-26 $3.00 85384-TC $7.00 85385 $16.00 85385-26 $5.00 85385-TC $11.00 85390 $10.00 85390-26 $2.00 85390-TC $7.00 85396 $22.00 85400 $12.00 85400-26 $3.00 85400-TC $8.00 85410 $12.00 85410-26 $3.00 85410-TC $8.00 85415 $28.00 85415-26 $10.00 85415-TC $18.00 85420 $16.00 85420-26 $3.00 85420-TC $13.00 85421 $39.00 85421-26 $12.00 85421-TC $26.00 85441 $7.00 85441-26 $2.00 85441-TC $5.00 85445 $16.00 85445-26 $5.00 85445-TC $11.00 85460 $15.00 85460-26 $4.00 85460-TC $11.00 85461 $12.00 85461-26 $3.00

Part A, 134



Pathology & Laboratory CPT Code MRA 85635-26 $8.00 85635-TC $18.00 85651 $8.00 85651-26 $2.00 85651-TC $6.00 85652 $8.00 85652-26 $2.00 85652-TC $6.00 85660 $10.00 85660-26 $3.00 85660-TC $6.00 85670 $13.00 85670-26 $3.00 85670-TC $10.00 85675 $13.00 85675-26 $4.00 85675-TC $8.00 85705 $13.00 85705-26 $4.00 85705-TC $8.00 85730 $11.00 85730-26 $3.00 85730-TC $7.00 85732 $17.00 85732-26 $5.00 85732-TC $12.00 85810 $19.00 85810-26 $4.00 85810-TC $15.00 85999 BR 85999-26 BR 85999-TC BR 86000 $16.00 86000-26 $5.00 86000-TC $11.00 86001 $12.00 86001-26 $4.00 86001-TC $8.00 86003 $6.00 86003-26 $2.00 86003-TC $3.00 86005 $11.00 86005-26 $4.00 86005-TC $6.00 86021 $41.00 86021-26 $12.00 86021-TC $29.00 86022 $57.00 86022-26 $18.00 86022-TC $39.00


Pathology & Laboratory CPT Code MRA 86023 $28.00 86023-26 $10.00 86023-TC $18.00 86038 $22.00 86038-26 $7.00 86038-TC $15.00 86039 $19.00 86039-26 $6.00 86039-TC $13.00 86060 $13.00 86060-26 $3.00 86060-TC $10.00 86063 $21.00 86063-26 $6.00 86063-TC $15.00 86077 $91.00 86077-26 $26.00 86077-TC $64.00 86078 $91.00 86078-26 $26.00 86078-TC $64.00 86079 $79.00 86079-26 $25.00 86079-TC $52.00 86140 $14.00 86140-26 $4.00 86140-TC $10.00 86141 BR 86141-26 BR 86141-TC BR 86146 $58.00 86146-26 $19.00 86146-TC $39.00 86147 $53.00 86147-26 $16.00 86147-TC $36.00 86148 $59.00 86148-26 $21.00 86148-TC $38.00 86153-26 $35.00 86155 $26.00 86155-26 $8.00 86155-TC $18.00 86156 $11.00 86156-26 $3.00 86156-TC $7.00 86157 $13.00 86157-26 $4.00 86157-TC $8.00 86160 $21.00

Part A, 135


Pathology & Laboratory CPT Code MRA 86160-26 $5.00 86160-TC $16.00 86161 $21.00 86161-26 $5.00 86161-TC $16.00 86162 $54.00 86162-26 $18.00 86162-TC $36.00 86171 $25.00 86171-26 $7.00 86171-TC $18.00 86185 $19.00 86185-26 $6.00 86185-TC $13.00 86215 $36.00 86215-26 $12.00 86215-TC $23.00 86225 $36.00 86225-26 $11.00 86225-TC $24.00 86226 $24.00 86226-26 $8.00 86226-TC $16.00 86235 $33.00 86235-26 $10.00 86235-TC $22.00 86243 $50.00 86243-26 $15.00 86243-TC $35.00 86255 $25.00 86255-26 $8.00 86255-TC $17.00 86256 $25.00 86256-26 $8.00 86256-TC $17.00 86277 $41.00 86277-26 $14.00 86277-TC $26.00 86280 $15.00 86280-26 $3.00 86280-TC $12.00 86294 BR 86294-26 BR 86294-TC BR 86300 $47.00 86300-26 $15.00 86300-TC $32.00 86301 $47.00 86301-26 $15.00 86301-TC $32.00

Pathology & Laboratory CPT Code MRA 86304 $47.00 86304-26 $15.00 86304-TC $32.00 86308 $8.00 86308-26 $3.00 86308-TC $5.00 86309 $12.00 86309-26 $3.00 86309-TC $8.00 86310 $19.00 86310-26 $6.00 86310-TC $13.00 86316 $37.00 86316-26 $11.00 86316-TC $25.00 86317 $31.00 86317-26 $10.00 86317-TC $20.00 86318 $23.00 86318-26 $10.00 86318-TC $14.00 86320 $49.00 86320-26 $19.00 86320-TC $29.00 86325 $49.00 86325-26 $16.00 86325-TC $33.00 86327 $62.00 86327-26 $19.00 86327-TC $42.00 86329 $37.00 86329-26 $12.00 86329-TC $24.00 86331 $22.00 86331-26 $6.00 86331-TC $15.00 86332 $54.00 86332-26 $18.00 86332-TC $36.00 86334 $65.00 86334-26 $18.00 86334-TC $45.00 86335 BR 86335-26 $20.00 86335-TC BR 86336 BR 86336-26 BR 86336-TC BR 86337 $54.00 86337-26 $18.00



Part A, 136


Pathology & Laboratory CPT Code MRA 86485-26 $4.00 86485-TC $8.00 86486 $6.00 86490 $17.00 86490-26 $5.00 86490-TC $12.00 86510 $13.00 86510-26 $4.00 86510-TC $8.00 86580 $13.00 86580-26 $4.00 86580-TC $8.00 86590 $18.00 86590-26 $6.00 86590-TC $12.00 86592 $8.00 86592-26 $2.00 86592-TC $6.00 86593 $11.00 86593-26 $3.00 86593-TC $7.00 86602 $17.00 86602-26 $5.00 86602-TC $12.00 86603 $20.00 86603-26 $6.00 86603-TC $14.00 86606 $24.00 86606-26 $8.00 86606-TC $16.00 86609 $20.00 86609-26 $6.00 86609-TC $14.00 86611 $23.00 86611-26 $8.00 86611-TC $15.00 86612 $21.00 86612-26 $6.00 86612-TC $15.00 86615 $21.00 86615-26 $6.00 86615-TC $15.00 86617 $29.00 86617-26 $10.00 86617-TC $19.00 86618 $26.00 86618-26 $8.00 86618-TC $18.00 86619 $21.00 86619-26 $6.00




Part A, 137






Part A, 138


Pathology & Laboratory CPT Code MRA 86821 $123.00 86821-26 $36.00 86821-TC $86.00 86822 $96.00 86822-26 $32.00 86822-TC $64.00 86849 BR 86849-26 BR 86849-TC BR 86850 $10.00 86850-26 $3.00 86850-TC $6.00 86860 $44.00 86860-26 $15.00 86860-TC $29.00 86870 $17.00 86870-26 $6.00 86870-TC $11.00 86880 $13.00 86880-26 $4.00 86880-TC $8.00 86885 $15.00 86885-26 $4.00 86885-TC $11.00 86886 $14.00 86886-26 $4.00 86886-TC $10.00 86890 $67.00 86890-26 $11.00 86890-TC $54.00 86891 $91.00 86891-26 $26.00 86891-TC $64.00 86900 $10.00 86900-26 $3.00 86900-TC $6.00 86901 $10.00 86901-26 $3.00 86901-TC $6.00 86904 $19.00 86904-26 $6.00 86904-TC $13.00 86905 $7.00 86905-26 $1.00 86905-TC $6.00 86906 $11.00 86906-26 $3.00 86906-TC $7.00 86910 $83.00 86910-26 $24.00



Pathology & Laboratory CPT Code MRA 86975-26 $16.00 86975-TC $37.00 86976 $53.00 86976-26 $16.00 86976-TC $37.00 86977 $53.00 86977-26 $16.00 86977-TC $37.00 86978 $65.00 86978-26 $19.00 86978-TC $44.00 86985 $35.00 86985-26 $12.00 86985-TC $23.00 86999 BR 86999-26 BR 86999-TC BR 87003 $40.00 87003-26 $13.00 87003-TC $26.00 87015 $14.00 87015-26 $5.00 87015-TC $9.00 87040 $18.00 87040-26 $6.00 87040-TC $12.00 87045 $18.00 87045-26 $6.00 87045-TC $11.00 87046 $5.00 87046-26 $2.00 87046-TC $3.00 87070 $14.00 87070-26 $4.00 87070-TC $10.00 87071 $11.00 87071-26 $3.00 87071-TC $8.00 87073 $11.00 87073-26 $3.00 87073-TC $8.00 87075 $18.00 87075-26 $6.00 87075-TC $12.00 87076 $24.00 87076-26 $8.00 87076-TC $16.00 87077 $16.00 87077-26 $5.00 87077-TC $11.00

Part A, 139





Pathology & Laboratory CPT Code MRA 87197-26 $10.00 87197-TC $19.00 87205 $11.00 87205-26 $3.00 87205-TC $7.00 87206 $15.00 87206-26 $3.00 87206-TC $12.00 87207 $10.00 87207-26 $3.00 87207-TC $6.00 87210 $8.00 87210-26 $2.00 87210-TC $6.00 87220 $12.00 87220-26 $4.00 87220-TC $7.00 87230 $35.00 87230-26 $11.00 87230-TC $23.00 87250 $33.00 87250-26 $13.00 87250-TC $19.00 87252 $44.00 87252-26 $14.00 87252-TC $31.00 87253 $33.00 87253-26 $10.00 87253-TC $22.00 87254 $11.00 87254-26 $3.00 87254-TC $8.00 87255 BR 87255-26 BR 87255-TC BR 87260 $26.00 87260-26 $8.00 87260-TC $18.00 87265 $26.00 87265-26 $8.00 87265-TC $18.00 87267 BR 87267-26 BR 87267-TC BR 87270 $26.00 87270-26 $8.00 87270-TC $18.00 87271 BR 87271-26 BR 87271-TC BR

Part A, 140






Part A, 141






Part A, 142


Pathology & Laboratory CPT Code MRA 87592 $88.00 87592-26 $28.00 87592-TC $58.00 87650 $42.00 87650-26 $13.00 87650-TC $28.00 87651 $73.00 87651-26 $23.00 87651-TC $48.00 87652 $86.00 87652-26 $28.00 87652-TC $56.00 87797 $42.00 87797-26 $13.00 87797-TC $28.00 87798 $73.00 87798-26 $23.00 87798-TC $48.00 87799 $88.00 87799-26 $28.00 87799-TC $58.00 87800 $46.00 87800-26 $15.00 87800-TC $31.00 87801 $81.00 87801-26 $26.00 87801-TC $54.00 87802 BR 87802-26 BR 87802-TC BR 87803 BR 87803-26 BR 87803-TC BR 87804 BR 87804-26 BR 87804-TC BR 87810 $26.00 87810-26 $8.00 87810-TC $18.00 87850 $26.00 87850-26 $8.00 87850-TC $18.00 87880 $26.00 87880-26 $8.00 87880-TC $18.00 87899 $26.00 87899-26 $8.00 87899-TC $18.00 87901 $594.00 87901-26 $196.00

Pathology & Laboratory CPT Code MRA 87901-TC $398.00 87902 BR 87902-26 BR 87902-TC BR 87903 $1,126.00 87903-26 $371.00 87903-TC $755.00 87904 $59.00 87904-26 $20.00 87904-TC $39.00 87999 BR 87999-26 BR 87999-TC BR 88000 $445.00 88000-26 $445.00 88000-TC BR 88005 $500.00 88005-26 $500.00 88005-TC BR 88007 $556.00 88007-26 $556.00 88007-TC BR 88020 $556.00 88020-26 $556.00 88020-TC BR 88025 $610.00 88025-26 $610.00 88025-TC BR 88027 $666.00 88027-26 $666.00 88027-TC BR 88036 $477.00 88036-26 $477.00 88036-TC BR 88037 $389.00 88037-26 $389.00 88037-TC BR 88040 $1,445.00 88040-26 $1,445.00 88040-TC BR 88045 BR 88045-26 BR 88045-TC BR 88099 BR 88099-26 BR 88099-TC BR 88104 $49.00 88104-26 $37.00 88104-TC $10.00 88106 $54.00


Pathology & Laboratory CPT Code MRA 88106-26 $16.00 88106-TC $38.00 88108 $59.00 88108-26 $47.00 88108-TC $11.00 88112 $121.00 88112-26 $65.00 88112-TC $56.00 88120 $619.00 88120-26 $59.00 88120-TC $560.00 88121 $535.00 88121-26 $51.00 88121-TC $484.00 88125 $70.00 88125-26 $20.00 88125-TC $48.00 88130 $25.00 88130-26 $7.00 88130-TC $18.00 88140 $18.00 88140-26 $5.00 88140-TC $13.00 88141 $33.00 88141-26 BR 88141-TC BR 88142 $82.00 88142-26 $21.00 88142-TC $59.00 88143 $94.00 88143-26 $33.00 88143-TC $59.00 88147 $82.00 88147-26 BR 88147-TC $82.00 88148 $104.00 88148-26 $21.00 88148-TC $82.00 88150 $13.00 88150-26 $3.00 88150-TC $9.00 88152 $46.00 88152-26 $8.00 88152-TC $38.00 88153 $82.00 88153-26 $21.00 88153-TC $59.00 88154 $104.00 88154-26 $21.00 88154-TC $82.00

Part A, 143


Pathology & Laboratory CPT Code MRA 88155 $14.00 88155-26 $3.00 88155-TC $10.00 88160 $45.00 88160-26 $14.00 88160-TC $24.00 88161 $64.00 88161-26 $19.00 88161-TC $37.00 88162 $77.00 88162-26 $22.00 88162-TC $53.00 88164 $54.00 88164-26 $21.00 88164-TC $33.00 88165 $72.00 88165-26 $33.00 88165-TC $38.00 88166 $82.00 88166-26 $21.00 88166-TC $59.00 88167 $87.00 88167-26 $26.00 88167-TC $59.00 88172 $70.00 88172-26 $54.00 88172-TC $14.00 88173 $95.00 88173-26 $95.00 88173-TC $26.00 88174 BR 88174-26 BR 88174-TC BR 88175 BR 88175-26 BR 88175-TC BR 88177 $30.00 88177-26 $22.00 88177-TC $8.00 88182 $88.00 88182-26 $33.00 88182-TC $54.00 88184 $51.00 88185 $25.00 88187 $69.00 88188 $86.00 88189 $113.00 88199 BR 88199-26 BR 88199-TC BR

Pathology & Laboratory CPT Code MRA 88233 $243.00 88233-26 $73.00 88233-TC $170.00 88235 $256.00 88235-26 $76.00 88235-TC $177.00 88240 $21.00 88240-26 $6.00 88240-TC $15.00 88241 $21.00 88241-26 $6.00 88241-TC $15.00 88300 $24.00 88300-26 $19.00 88300-TC $5.00 88302 $53.00 88302-26 $42.00 88302-TC $11.00 88304 $70.00 88304-26 $54.00 88304-TC $14.00 88305 $108.00 88305-26 $86.00 88305-TC $21.00 88307 $210.00 88307-26 $168.00 88307-TC $41.00 88309 $322.00 88309-26 $258.00 88309-TC $64.00 88311 $23.00 88311-26 $19.00 88311-TC $4.00 88312 $23.00 88312-26 $7.00 88312-TC $16.00 88313 $23.00 88313-26 $7.00 88313-TC $16.00 88314 $21.00 88314-26 $6.00 88314-TC $15.00 88319 $26.00 88319-26 $13.00 88319-TC $14.00 88321 $43.00 88321-26 $43.00 88321-TC BR 88323 $61.00 88323-26 $61.00


Pathology & Laboratory CPT Code MRA 88323-TC $32.00 88325 $54.00 88325-26 $54.00 88325-TC BR 88329 $51.00 88329-26 $51.00 88329-TC BR 88331 $102.00 88331-26 $70.00 88331-TC $33.00 88332 $53.00 88332-26 $36.00 88332-TC $17.00 88333 $89.00 88333-26 $67.00 88333-TC $22.00 88334 $47.00 88334-26 $33.00 88334-TC $14.00 88341 $90.00 88341-26 $28.00 88341-TC $62.00 88342 $53.00 88342-26 $36.00 88342-TC $17.00 88344 $174.00 88344-26 $41.00 88344-TC $133.00 88346 $96.00 88346-26 $66.00 88346-TC $28.00 88348 $191.00 88348-26 $145.00 88348-TC $44.00 88350 $72.00 88350-26 $29.00 88350-TC $44.00 88355 $108.00 88355-26 $80.00 88355-TC $26.00 88356 $108.00 88356-26 $80.00 88356-TC $26.00 88358 $108.00 88358-26 $80.00 88358-TC $26.00 88360 $110.00 88360-26 $62.00 88360-TC $49.00 88361 $139.00

Part A, 144


Pathology & Laboratory CPT Code MRA 88361-26 $55.00 88361-TC $84.00 88362 $251.00 88362-26 $119.00 88362-TC $132.00 88363 $22.00 88364 $135.00 88364-26 $35.00 88364-TC $100.00 88365 $24.00 88365-26 $24.00 88365-TC $68.00 88366 $263.00 88366-26 $65.00 88366-TC $198.00 88367 $210.00 88367-26 $72.00 88367-TC $138.00 88368 $190.00 88368-26 $78.00 88368-TC $112.00 88369 $108.00 88369-26 $32.00 88369-TC $77.00 88371 $34.00 88371-26 $10.00 88371-TC $23.00 88372 $38.00 88372-26 $11.00 88372-TC $26.00 88373 $75.00 88373-26 $21.00 88373-TC $54.00 88374 $346.00 88374-26 $46.00 88374-TC $300.00 88375 $20.00 88377 $412.00 88377-26 $67.00 88377-TC $346.00 88380 $159.00 88380-26 $71.00 88380-TC $88.00 88381 $213.00 88381-26 $54.00 88381-TC $159.00 88387 $36.00 88387-26 $29.00 88387-TC $6.00 88388 $33.00

Pathology & Laboratory CPT Code MRA 88388-26 $24.00 88388-TC $9.00 88399 BR 88399-26 BR 88399-TC BR 89049 $190.00 89050 $10.00 89050-26 $3.00 89050-TC $6.00 89051 $13.00 89051-26 $4.00 89051-TC $8.00 89055 BR 89055-26 BR 89055-TC BR 89060 $13.00 89060-26 $5.00 89060-TC $8.00 89125 $14.00 89125-26 $4.00 89125-TC $10.00 89160 $6.00 89160-26 $2.00 89160-TC $4.00 89190 $10.00 89190-26 $3.00 89190-TC $6.00 89220 $17.00 89230 $5.00 G0124 $24.00 G0141 $24.00 G0416 $651.00 G0416-26 $184.00 G0416-TC $467.00 G0452-26 $19.00 G0455 $126.00


Part A, 145


Medicine CPT Code 90460 90461 90471 90472 90473 90474 90632 90636 90675 90746 90749 90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90849 90853 90865 90870 90875 90876 90880 90882 90885 90887 90889 90899 90901 90911 90935 90937 90940 90945 90947 90951 90954 90955 90956 90957 90958

MRA $25.00 $13.00 $4.00 $4.00 $13.00 $9.00 BR BR BR BR BR $14.00 $134.00 $144.00 $65.00 $66.00 $86.00 $84.00 $129.00 $111.00 $134.00 $64.00 $85.00 $93.00 $110.00 $32.00 $32.00 $143.00 $94.00 $74.00 $112.00 $112.00 $104.00 $49.00 $77.00 BR BR $46.00 $82.00 $76.00 $226.00 BR $80.00 $125.00 $943.00 $818.00 $461.00 $321.00 $651.00 $440.00

Medicine CPT Code 90959 90960 90961 90962 90963 90964 90965 90966 90967 90968 90969 90970 90997 90999 91010 91010-26 91010-TC 91013 91013-26 91013-TC 91020 91020-26 91020-TC 91022 91022-26 91022-TC 91030 91030-26 91030-TC 91034 91034-26 91034-TC 91035 91035-26 91035-TC 91037 91037-26 91037-TC 91038 91038-26 91038-TC 91040 91040-26 91040-TC 91065 91065-26 91065-TC 91110 91110-26 91110-TC

MRA $298.00 $287.00 $241.00 $186.00 $552.00 $481.00 $456.00 $241.00 $18.00 $15.00 $15.00 $8.00 $115.00 BR $116.00 $76.00 $32.00 $24.00 $10.00 $14.00 $60.00 $49.00 $9.00 $227.00 $77.00 $150.00 $57.00 $47.00 $8.00 $240.00 $52.00 $188.00 $474.00 $84.00 $390.00 $152.00 $52.00 $100.00 $130.00 $59.00 $72.00 $463.00 $52.00 $411.00 $34.00 $23.00 $14.00 $928.00 $185.00 $743.00


Medicine CPT Code 91111 91111-26 91111-TC 91112 91112-26 91112-TC 91117 91120 91120-26 91120-TC 91122 91122-26 91122-TC 91132 91132-26 91132-TC 91133 91133-26 91133-TC 91200 91200-26 91200-TC 91299 91299-26 91299-TC 92002 92004 92012 92014 92015 92018 92019 92020 92025 92025-26 92025-TC 92060 92060-26 92060-TC 92065 92065-26 92065-TC 92071 92072 92081 92081-26 92081-TC 92082 92082-26 92082-TC

MRA $743.00 $53.00 $690.00 $1,083.00 $113.00 $969.00 $152.00 $457.00 $52.00 $405.00 $169.00 $122.00 $37.00 $156.00 $28.00 $127.00 $174.00 $34.00 $139.00 $32.00 $13.00 $19.00 BR BR BR $63.00 $98.00 $53.00 $75.00 $34.00 $80.00 $70.00 $31.00 $29.00 $17.00 $13.00 $40.00 $32.00 $7.00 $34.00 $19.00 $6.00 $39.00 $140.00 $32.00 $19.00 $6.00 $48.00 $24.00 $9.00

Part A, 146


Medicine CPT Code 92083 92083-26 92083-TC 92100 92132 92132-26 92132-TC 92133 92133-26 92133-TC 92134 92134-26 92134-TC 92136 92136-26 92136-TC 92140 92145 92145-26 92145-TC 92225 92226 92227 92228 92228-26 92228-TC 92230 92235 92235-26 92235-TC 92240 92240-26 92240-TC 92250 92250-26 92250-TC 92260 92265 92265-26 92265-TC 92270 92270-26 92270-TC 92275 92275-26 92275-TC 92283 92283-26 92283-TC 92284

MRA $59.00 $31.00 $14.00 $40.00 $36.00 $20.00 $16.00 $45.00 $29.00 $16.00 $46.00 $30.00 $16.00 $93.00 $29.00 $63.00 $38.00 $15.00 $9.00 $7.00 $45.00 $39.00 $14.00 $35.00 $22.00 $14.00 $58.00 $104.00 $46.00 $53.00 $132.00 $60.00 $67.00 $40.00 $24.00 $7.00 $20.00 $53.00 $37.00 $10.00 $64.00 $45.00 $19.00 $80.00 $56.00 $17.00 $24.00 $10.00 $5.00 $192.00

Medicine CPT Code 92284-26 92284-TC 92285 92285-26 92285-TC 92286 92286-26 92286-TC 92287 92287-26 92287-TC 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92340 92341 92342 92358 92370 92371 92499 92499-26 92499-TC 92502 92504 92507 92508 92511 92512 92516 92520 92521 92522 92523 92524 92526 92531 92532 92533 92534 92537 92537-26 92537-TC

MRA $151.00 $46.00 $26.00 $12.00 $6.00 $91.00 $53.00 $29.00 $99.00 $48.00 $77.00 $86.00 $78.00 $89.00 $70.00 $54.00 $44.00 $59.00 $39.00 $14.00 $44.00 $32.00 $43.00 $43.00 $24.00 $35.00 $18.00 BR BR BR $101.00 $24.00 $40.00 $42.00 $81.00 $46.00 $36.00 $47.00 $114.00 $93.00 $193.00 $97.00 $48.00 $10.00 $14.00 $41.00 BR $41.00 $32.00 $9.00


Medicine CPT Code 92538 92538-26 92538-TC 92540 92540-26 92540-TC 92541 92541-26 92541-TC 92542 92542-26 92542-TC 92544 92544-26 92544-TC 92545 92545-26 92545-TC 92546 92546-26 92546-TC 92547 92548 92548-26 92548-TC 92550 92551 92552 92553 92555 92556 92557 92560 92561 92562 92563 92564 92565 92567 92568 92570 92571 92572 92575 92576 92577 92579 92582 92583 92584

MRA $21.00 $16.00 $5.00 $102.00 $81.00 $22.00 $37.00 $25.00 $9.00 $33.00 $20.00 $10.00 $26.00 $16.00 $8.00 $22.00 $14.00 $8.00 $29.00 $17.00 $9.00 $21.00 $92.00 $30.00 $59.00 $21.00 $17.00 $16.00 $24.00 $14.00 $21.00 $46.00 $23.00 $27.00 $15.00 $14.00 $17.00 $15.00 $20.00 $14.00 $33.00 $14.00 $3.00 $11.00 $17.00 $28.00 $28.00 $28.00 $34.00 $94.00

Part A, 147


Medicine CPT Code 92585 92585-26 92585-TC 92586 92587 92587-26 92587-TC 92588 92588-26 92588-TC 92590 92591 92592 92593 92594 92595 92596 92597 92603 92604 92605 92606 92607 92608 92609 92610 92611 92612 92613 92614 92615 92616 92617 92618 92620 92621 92625 92626 92627 92640 92700 92920 92924 92928 92933 92937 92941 92943 92950 92953

MRA $114.00 $52.00 $70.00 $70.00 $58.00 $8.00 $49.00 $78.00 $20.00 $57.00 $41.00 BR BR BR BR BR $22.00 $96.00 $88.00 $60.00 $94.00 $84.00 $109.00 $22.00 $59.00 $42.00 $46.00 $173.00 $43.00 $134.00 $39.00 $183.00 $48.00 $34.00 $45.00 $12.00 $45.00 $86.00 $22.00 $53.00 BR $561.00 $668.00 $623.00 $697.00 $623.00 $699.00 $699.00 $203.00 $35.00

Medicine CPT Code 92960 92961 92970 92971 92973 92974 92975 92977 92978 92978-26 92978-TC 92979 92979-26 92979-TC 92986 92987 92990 92992 92993 92997 92998 93000 93005 93010 93015 93016 93017 93018 93024 93024-26 93024-TC 93025 93025-26 93025-TC 93040 93041 93042 93050 93050-26 93050-TC 93224 93225 93226 93227 93228 93229 93260 93260-26 93260-TC 93261

MRA $162.00 $239.00 $201.00 $100.00 $174.00 $197.00 $400.00 $302.00 $269.00 $95.00 $170.00 $163.00 $76.00 $86.00 $1,222.00 $1,271.00 $974.00 BR BR $765.00 $331.00 $26.00 $16.00 $12.00 $104.00 $25.00 $63.00 $54.00 $111.00 $71.00 $42.00 $277.00 $40.00 $299.00 $14.00 $31.00 $9.00 $18.00 $9.00 $9.00 $159.00 $46.00 $83.00 $50.00 $27.00 $669.00 $68.00 $45.00 $22.00 $61.00


Medicine CPT Code 93261-26 93261-TC 93268 93270 93271 93272 93278 93278-26 93278-TC 93279 93279-26 93279-TC 93280 93280-26 93280-TC 93281 93281-26 93281-TC 93282 93282-26 93282-TC 93283 93283-26 93283-TC 93284 93284-26 93284-TC 93285 93285-26 93285-TC 93286 93286-26 93286-TC 93287 93287-26 93287-TC 93288 93288-26 93288-TC 93289 93289-26 93289-TC 93290 93290-26 93290-TC 93291 93291-26 93291-TC 93292 93292-26

MRA $39.00 $22.00 $109.00 $46.00 $90.00 $28.00 $58.00 $24.00 $44.00 $50.00 $33.00 $17.00 $59.00 $39.00 $20.00 $68.00 $45.00 $23.00 $63.00 $43.00 $20.00 $82.00 $58.00 $24.00 $90.00 $63.00 $27.00 $42.00 $26.00 $16.00 $27.00 $15.00 $12.00 $36.00 $23.00 $13.00 $37.00 $21.00 $16.00 $66.00 $46.00 $19.00 $31.00 $21.00 $9.00 $36.00 $21.00 $15.00 $32.00 $21.00

Part A, 148


Medicine CPT Code 93292-TC 93293 93293-26 93293-TC 93294 93295 93296 93297 93298 93303 93303-26 93303-TC 93304 93304-26 93304-TC 93306 93306-26 93306-TC 93307 93307-26 93307-TC 93308 93308-26 93308-TC 93312 93312-26 93312-TC 93313 93314 93314-26 93314-TC 93315 93315-26 93315-TC 93316 93317 93317-26 93317-TC 93318 93318-26 93318-TC 93320 93320-26 93320-TC 93321 93321-26 93321-TC 93325 93325-26 93325-TC

MRA $11.00 $54.00 $16.00 $38.00 $34.00 $68.00 $26.00 $27.00 $27.00 $215.00 $70.00 $144.00 $114.00 $43.00 $73.00 $229.00 $64.00 $165.00 $196.00 $56.00 $144.00 $118.00 $46.00 $75.00 $322.00 $140.00 $182.00 $76.00 $212.00 $65.00 $144.00 $287.00 $144.00 $141.00 $78.00 $236.00 $95.00 $141.00 $412.00 $114.00 $384.00 $86.00 $30.00 $65.00 $50.00 $10.00 $42.00 $114.00 $4.00 $110.00

Medicine CPT Code 93350 93350-26 93350-TC 93351 93351-26 93351-TC 93352 93355 93451 93451-26 93451-TC 93452 93452-26 93452-TC 93453 93453-26 93453-TC 93454 93454-26 93454-TC 93455 93455-26 93455-TC 93456 93456-26 93456-TC 93457 93457-26 93457-TC 93458 93458-26 93458-TC 93459 93459-26 93459-TC 93460 93460-26 93460-TC 93461 93461-26 93461-TC 93462 93463 93464 93464-26 93464-TC 93503 93505 93505-26 93505-TC

MRA $216.00 $77.00 $66.00 $282.00 $86.00 $195.00 $34.00 $230.00 $790.00 $151.00 $638.00 $887.00 $265.00 $622.00 $1,149.00 $347.00 $801.00 $903.00 $267.00 $637.00 $1,052.00 $308.00 $744.00 $1,132.00 $341.00 $791.00 $1,280.00 $383.00 $897.00 $1,084.00 $326.00 $758.00 $1,197.00 $367.00 $830.00 $1,284.00 $408.00 $875.00 $1,468.00 $451.00 $1,018.00 $215.00 $109.00 $284.00 $99.00 $186.00 $187.00 $318.00 $248.00 $74.00


Medicine CPT Code 93530 93530-26 93530-TC 93531 93531-26 93531-TC 93532 93532-26 93532-TC 93533 93533-26 93533-TC 93561 93561-26 93561-TC 93562 93562-26 93562-TC 93563 93564 93565 93566 93567 93568 93571 93571-26 93571-TC 93572 93572-26 93572-TC 93580 93581 93582 93583 93600 93600-26 93600-TC 93602 93602-26 93602-TC 93603 93603-26 93603-TC 93609 93609-26 93609-TC 93610 93610-26 93610-TC 93612

MRA $872.00 $250.00 $634.00 $2,268.00 $467.00 $1,815.00 $2,317.00 $569.00 $1,766.00 $2,131.00 $352.00 $1,766.00 $59.00 $47.00 $20.00 $46.00 $33.00 $13.00 $57.00 $58.00 $44.00 $173.00 $142.00 $154.00 $270.00 $93.00 $170.00 $222.00 $74.00 $155.00 $974.00 $1,303.00 $697.00 $776.00 $198.00 $129.00 $73.00 $159.00 $119.00 $42.00 $187.00 $127.00 $63.00 $578.00 $481.00 $101.00 $214.00 $166.00 $52.00 $224.00

Part A, 149


Medicine CPT Code 93612-26 93612-TC 93613 93615 93615-26 93615-TC 93616 93616-26 93616-TC 93618 93618-26 93618-TC 93619 93619-26 93619-TC 93620 93620-26 93620-TC 93621 93621-26 93621-TC 93622 93622-26 93622-TC 93623 93623-26 93623-TC 93624 93624-26 93624-TC 93631 93631-26 93631-TC 93640 93640-26 93640-TC 93641 93641-26 93641-TC 93642 93642-26 93642-TC 93644 93644-26 93644-TC 93650 93653 93654 93655 93656

MRA $167.00 $61.00 $377.00 $62.00 $49.00 $12.00 $94.00 $82.00 $12.00 $399.00 $258.00 $148.00 $717.00 $444.00 $290.00 $358.00 $272.00 $91.00 BR $769.00 BR BR $771.00 BR BR $167.00 BR $333.00 $256.00 $74.00 $651.00 $420.00 $239.00 $467.00 $230.00 $269.00 $613.00 $360.00 $269.00 $549.00 $295.00 $269.00 $282.00 $176.00 $106.00 $639.00 $865.00 $1,152.00 $432.00 $1,153.00

Medicine CPT Code 93657 93660 93660-26 93660-TC 93662 93662-26 93662-TC 93701 93701-26 93701-TC 93702 93724 93724-26 93724-TC 93740 93740-26 93740-TC 93750 93770 93770-26 93770-TC 93784 93786 93788 93790 93797 93798 93799 93799-26 93799-TC 93880 93880-26 93880-TC 93882 93882-26 93882-TC 93886 93886-26 93886-TC 93888 93888-26 93888-TC 93890 93890-26 93890-TC 93892 93892-26 93892-TC 93893 93893-26

MRA $433.00 $162.00 $103.00 $61.00 BR $158.00 BR $36.00 $9.00 $27.00 $109.00 $411.00 $259.00 $148.00 $17.00 $12.00 $5.00 $55.00 NC NC NC NC NC NC NC $17.00 $38.00 BR BR BR $176.00 $31.00 $144.00 $117.00 $21.00 $95.00 $215.00 $50.00 $162.00 $142.00 $33.00 $109.00 $241.00 $55.00 $185.00 $256.00 $63.00 $193.00 $251.00 $63.00


Medicine CPT Code 93893-TC 93922 93922-26 93922-TC 93923 93923-26 93923-TC 93924 93924-26 93924-TC 93925 93925-26 93925-TC 93926 93926-26 93926-TC 93930 93930-26 93930-TC 93931 93931-26 93931-TC 93965 93965-26 93965-TC 93970 93970-26 93970-TC 93971 93971-26 93971-TC 93975 93975-26 93975-TC 93976 93976-26 93976-TC 93978 93978-26 93978-TC 93979 93979-26 93979-TC 93980 93980-26 93980-TC 93981 93981-26 93981-TC 93982

MRA $188.00 $60.00 $16.00 $44.00 $112.00 $28.00 $85.00 $122.00 $31.00 $92.00 $175.00 $31.00 $144.00 $117.00 $21.00 $96.00 $174.00 $26.00 $150.00 $118.00 $17.00 $101.00 $63.00 $26.00 $42.00 $189.00 $36.00 $154.00 $121.00 $23.00 $96.00 $277.00 $89.00 $181.00 $184.00 $59.00 $121.00 $177.00 $34.00 $143.00 $122.00 $23.00 $98.00 $183.00 $65.00 $105.00 $148.00 $25.00 $124.00 $10.00

Part A, 150


Medicine CPT Code 93990 93990-26 93990-TC 94002 94003 94004 94010 94010-26 94010-TC 94014 94015 94016 94060 94060-26 94060-TC 94070 94070-26 94070-TC 94150 94150-26 94150-TC 94200 94200-26 94200-TC 94250 94250-26 94250-TC 94375 94375-26 94375-TC 94400 94400-26 94400-TC 94450 94450-26 94450-TC 94452 94452-26 94452-TC 94453 94453-26 94453-TC 94610 94620 94620-26 94620-TC 94621 94621-26 94621-TC 94640

MRA $110.00 $14.00 $96.00 $84.00 $61.00 $45.00 $30.00 $12.00 $16.00 $39.00 $14.00 $26.00 $57.00 $18.00 $36.00 $32.00 $11.00 $19.00 $8.00 $6.00 $3.00 $17.00 $7.00 $9.00 $12.00 $8.00 $5.00 $34.00 $16.00 $17.00 $40.00 $24.00 $14.00 $37.00 $20.00 $15.00 $52.00 $16.00 $36.00 $74.00 $20.00 $53.00 $63.00 $91.00 $38.00 $54.00 $122.00 $71.00 $52.00 $19.00

Medicine CPT Code 94642 94644 94645 94660 94662 94664 94667 94668 94669 94680 94680-26 94680-TC 94681 94681-26 94681-TC 94690 94690-26 94690-TC 94726 94726-26 94726-TC 94727 94727-26 94727-TC 94728 94728-26 94728-TC 94729 94729-26 94729-TC 94750 94750-26 94750-TC 94760 94761 94762 94770 94770-26 94770-TC 94799 94799-26 94799-TC 95004 95012 95017 95018 95024 95027 95028 95044

MRA BR $36.00 $14.00 $54.00 $38.00 $18.00 $23.00 $16.00 $35.00 $47.00 $23.00 $22.00 $60.00 $12.00 $43.00 $24.00 $4.00 $20.00 $53.00 $13.00 $41.00 $42.00 $13.00 $30.00 $40.00 $13.00 $28.00 $54.00 $9.00 $45.00 $37.00 $14.00 $21.00 $9.00 $20.00 $30.00 $21.00 $9.00 $12.00 BR BR BR $3.00 $19.00 $8.00 $20.00 $3.00 $5.00 $8.00 $7.00


Medicine CPT Code 95052 95056 95060 95065 95070 95071 95076 95079 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 95250 95251 95803 95803-26 95803-TC 95805 95805-26 95805-TC 95806 95806-26 95806-TC 95807 95807-26 95807-TC 95808 95808-26 95808-TC 95810 95810-26 95810-TC 95811 95811-26 95811-TC

MRA $9.00 $6.00 $13.00 $7.00 $82.00 $105.00 $117.00 $84.00 $10.00 $9.00 BR BR BR BR BR BR BR $9.00 $17.00 $24.00 $33.00 $32.00 $36.00 $7.00 $13.00 $103.00 BR $114.00 $28.00 $151.00 $44.00 $107.00 $334.00 $94.00 $237.00 $232.00 $109.00 $137.00 $367.00 $98.00 $256.00 $456.00 $149.00 $256.00 $521.00 $183.00 $256.00 $644.00 $196.00 $423.00

Part A, 151


Medicine CPT Code 95812 95812-26 95812-TC 95813 95813-26 95813-TC 95816 95816-26 95816-TC 95819 95819-26 95819-TC 95822 95822-26 95822-TC 95824 95824-26 95824-TC 95827 95827-26 95827-TC 95829 95829-26 95829-TC 95830 95831 95832 95833 95834 95851 95852 95857 95860 95860-26 95860-TC 95861 95861-26 95861-TC 95863 95863-26 95863-TC 95864 95864-26 95864-TC 95865 95865-26 95865-TC 95866 95866-26 95866-TC

MRA $137.00 $58.00 $68.00 $177.00 $89.00 $68.00 $133.00 $54.00 $78.00 $115.00 $58.00 $56.00 $120.00 $58.00 $63.00 $51.00 $41.00 $10.00 $145.00 $59.00 $86.00 $328.00 $291.00 $6.00 $133.00 $26.00 $21.00 $34.00 $44.00 $18.00 $14.00 $40.00 $73.00 $53.00 $15.00 $113.00 $86.00 $28.00 $138.00 $102.00 $35.00 $177.00 $114.00 $67.00 $119.00 $92.00 $27.00 $80.00 $71.00 $9.00

Medicine CPT Code 95867 95867-26 95867-TC 95868 95868-26 95868-TC 95869 95869-26 95869-TC 95870 95870-26 95870-TC 95872 95872-26 95872-TC 95873 95873-26 95873-TC 95874 95874-26 95874-TC 95875 95875-26 95875-TC 95885 95885-26 95885-TC 95886 95886-26 95886-TC 95887 95887-26 95887-TC 95905 95905-26 95905-TC 95907 95907-26 95907-TC 95908 95908-26 95908-TC 95909 95909-26 95909-TC 95910 95910-26 95910-TC 95911 95911-26

MRA $66.00 $43.00 $21.00 $96.00 $71.00 $26.00 $29.00 $21.00 $8.00 $29.00 $21.00 $8.00 $104.00 $81.00 $22.00 $29.00 $21.00 $8.00 $30.00 $21.00 $8.00 $43.00 $34.00 $7.00 $59.00 $19.00 $40.00 $92.00 $47.00 $45.00 $87.00 $38.00 $48.00 $68.00 $3.00 $66.00 $95.00 $54.00 $42.00 $117.00 $67.00 $51.00 $142.00 $80.00 $61.00 $186.00 $107.00 $79.00 $226.00 $134.00


Medicine CPT Code 95911-TC 95912 95912-26 95912-TC 95913 95913-26 95913-TC 95921 95921-26 95921-TC 95922 95922-26 95922-TC 95923 95923-26 95923-TC 95924 95924-26 95924-TC 95925 95925-26 95925-TC 95926 95926-26 95926-TC 95927 95927-26 95927-TC 95928 95928-26 95928-TC 95929 95929-26 95929-TC 95930 95930-26 95930-TC 95933 95933-26 95933-TC 95937 95937-26 95937-TC 95938 95938-26 95938-TC 95939 95939-26 95939-TC 95940

MRA $92.00 $266.00 $161.00 $105.00 $308.00 $191.00 $117.00 $61.00 $46.00 $14.00 $65.00 $50.00 $14.00 $105.00 $47.00 $57.00 $147.00 $90.00 $57.00 $94.00 $53.00 $41.00 $66.00 $34.00 $34.00 $67.00 $34.00 $34.00 $175.00 $84.00 $91.00 $182.00 $84.00 $98.00 $44.00 $25.00 $11.00 $62.00 $33.00 $30.00 $40.00 $31.00 $9.00 $339.00 $47.00 $292.00 $495.00 $122.00 $373.00 $33.00

Part A, 152


Medicine CPT Code 95950 95950-26 95950-TC 95951 95951-26 95951-TC 95953 95953-26 95953-TC 95954 95954-26 95954-TC 95955 95955-26 95955-TC 95956 95956-26 95956-TC 95957 95957-26 95957-TC 95958 95958-26 95958-TC 95961 95961-26 95961-TC 95962 95962-26 95962-TC 95965 95965-26 95965-TC 95966 95966-26 95966-TC 95967 95967-26 95967-TC 95970 95971 95972 95974 95975 95978 95979 95980 95981 95982 95990

MRA $265.00 $84.00 $177.00 $34.00 $14.00 $20.00 $411.00 $165.00 $240.00 $208.00 $134.00 $23.00 $130.00 $59.00 $74.00 $541.00 $166.00 $314.00 $171.00 $104.00 $64.00 $296.00 $230.00 $66.00 $216.00 $166.00 $48.00 $227.00 $176.00 $48.00 BR $420.00 BR BR $210.00 BR BR $184.00 BR $22.00 $39.00 $78.00 $155.00 $88.00 $213.00 $98.00 $27.00 $10.00 $22.00 $57.00

Medicine CPT Code 95991 95992 95999 96000 96001 96002 96003 96004 96020 96020-26 96020-TC 96101 96102 96103 96105 96110 96111 96116 96118 96119 96120 96125 96127 96150 96151 96152 96153 96154 96155 96360 96361 96365 96366 96367 96368 96369 96370 96371 96372 96373 96374 96375 96401 96402 96405 96406 96409 96411 96413 96415

MRA $84.00 $44.00 BR $93.00 $111.00 $21.00 $20.00 $97.00 BR $156.00 BR $97.00 $44.00 $28.00 $68.00 $88.00 $68.00 $109.00 $130.00 $66.00 $48.00 $57.00 $5.00 $26.00 $25.00 $24.00 $6.00 $24.00 $22.00 $57.00 $15.00 $69.00 $19.00 $30.00 $20.00 $195.00 $15.00 $91.00 $25.00 $19.00 $56.00 $22.00 $53.00 $46.00 $57.00 $86.00 $122.00 $71.00 $173.00 $39.00



MRA $186.00 $85.00 $46.00 $46.00 $17.00 $54.00 $156.00 $193.00 $134.00 $153.00 $111.00 $28.00 $126.00 BR $62.00 $69.00 $38.00 $17.00 $70.00 $21.00 $24.00 $53.00 $152.00 $155.00 $214.00 BR $62.00 $29.00 $62.00 $29.00 BR BR $10.00 $16.00 $14.00 $15.00 $10.00 $15.00 $10.00 $9.00 $10.00 $16.00 $16.00 $13.00 $11.00 $19.00 $15.00 $22.00 $23.00 $24.00

Part A, 153



MRA $21.00 $19.00 $15.00 $26.00 $18.00 $23.00 $17.00 $22.00 $22.00 $24.00 $23.00 $23.00 $17.00 $83.00 $41.00 $49.00 $62.00 BR $34.00 $37.00 $121.00 BR $48.00 $35.00 $31.00 $28.00 $26.00 BR $26.00 $17.00 $7.00 $35.00 $27.00 $37.00 $30.00 $54.00 $26.00 $54.00 $26.00 NC $32.00 NC $23.00 NC NC $32.00 NC $23.00 $19.00 $9.00

Medicine CPT Code 98962 99000 99001 99002 99026 99027 99070 99071 99075 99078 99082 99090 99172 99173 99174 99175 99183 99184 99190 99191 99192 99195 99199 G0101 G0102 G0104 G0105 G0105-53 G0106 G0106-26 G0106-TC G0108 G0109 G0117 G0118 G0120 G0120-26 G0120-TC G0121 G0121-53 G0122 G0122-26 G0122-TC G0128 G0166 G0179 G0180 G0181 G0182 G0237

MRA $7.00 $6.00 $4.00 $35.00 BR BR BR NC See 440.13 NC BR BR BR $3.00 $8.00 $53.00 $123.00 $232.00 BR BR BR $16.00 NC $32.00 $18.00 $115.00 $344.00 $115.00 $165.00 $46.00 $119.00 $24.00 $14.00 $40.00 $27.00 $179.00 $46.00 $132.00 $344.00 $115.00 $177.00 $45.00 $132.00 $4.00 $138.00 $41.00 $54.00 $99.00 $102.00 $12.00


Medicine CPT Code G0238 G0239 G0248 G0249 G0250 G0268 G0270 G0271 G0277 G0281 G0283 G0329 G0403 G0404 G0405 G0422 G0423 G0424 G0453 G0454 G0459 G0473 G9157 G9187 P3001 Q0035 Q0035-26 Q0035-TC Q0091

MRA $13.00 $11.00 $168.00 $124.00 $9.00 $43.00 $22.00 $13.00 $45.00 $10.00 $10.00 $7.00 $17.00 $8.00 $9.00 $103.00 $103.00 $30.00 $33.00 $9.00 $49.00 $13.00 $112.00 $48.00 $24.00 $19.00 $8.00 $11.00 $37.00

Part A, 154


Evaluation & Management CPT Code MRA 99201 $35.00 99202 $58.00 99203 $58.00 99204 $84.00 99205 $84.00 99211 $19.00 99212 $31.00 99213 $40.00 99214 $40.00 99215 $65.00 99217 $65.00 99218 $65.00 99219 $109.00 99220 $152.00 99221 $66.00 99222 $109.00 99223 $152.00 99224 $40.00 99225 $73.00 99226 $105.00 99231 $33.00 99232 $54.00 99233 $77.00 99234 $129.00 99235 $173.00 99236 $213.00 99238 $66.00 99239 $88.00 99241 $54.00 99242 $88.00 99243 $117.00 99244 $163.00 99245 $212.00 99251 $54.00 99252 $70.00 99253 $96.00 99254 $138.00 99255 $190.00 99281 $18.00 99282 $28.00 99283 $60.00 99284 $94.00 99285 $103.00 99291 $192.00 99292 $95.00 99304 $66.00 99305 $88.00 99306 $108.00 99307 $34.00 99308 $56.00

Evaluation & Management CPT Code MRA 99309 $80.00 99310 $100.00 99315 $60.00 99316 $77.00 99318 $66.00 99324 $59.00 99325 $86.00 99326 $125.00 99327 $164.00 99328 $203.00 99334 $45.00 99335 $72.00 99336 $111.00 99337 $163.00 99339 $67.00 99340 $93.00 99341 $59.00 99342 $85.00 99343 $109.00 99344 $160.00 99345 $193.00 99347 $46.00 99348 $71.00 99349 $107.00 99350 $156.00 99354 $106.00 99355 $104.00 99356 $87.00 99357 $88.00 99360 $47.00 99363 $108.00 99364 $38.00 99366 $37.00 99367 $48.00 99368 $31.00 99374 $75.00 99375 $75.00 99377 $75.00 99378 $104.00 99379 $75.00 99380 $104.00 99406 $12.00 99407 $24.00 99408 $29.00 99409 $58.00 99415 $9.00 99416 $5.00 99450 NC 99455 $90.00 99456 BR


Evaluation & Management CPT Code MRA 99457 BR 99487 $52.00 99489 $41.00 99490 $41.00 99495 $164.00 99496 $232.00 99497 $86.00 99498 $75.00 99499 BR 99600 BR G0245 $58.00 G0246 $34.00 G0296 $29.00 G0337 $62.00 G0372 $13.00 G0396 $29.00 G0397 $56.00 G0402 $165.00 G0406 $39.00 G0407 $72.00 G0408 $104.00 G0409 $16.00

Part A, 155


Dental D-Code D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0270 D0272 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0415 D0425 D0460 D0470 D0472 D0473 D0474 D0480 D0502 D0999 D1110 D1310 D1320 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332

MRA $17.00 $13.00 $20.00 $36.00 $18.00 $20.00 $40.00 $10.00 $5.00 $12.00 $20.00 $7.00 $12.00 $20.00 $18.00 $36.00 $50.00 $204.00 $64.00 $105.00 $29.00 $40.00 $10.00 $34.00 $25.00 $13.00 $24.00 $30.00 BR BR BR $54.00 BR $29.00 $23.00 $48.00 $13.00 $21.00 $81.00 $121.00 $102.00 $143.00 $14.00 $38.00 $44.00 $54.00 $67.00 $40.00 $61.00 $66.00


MRA $81.00 $57.00 $43.00 $55.00 $63.00 $69.00 $163.00 $203.00 $293.00 $155.00 $259.00 $244.00 $302.00 $318.00 $348.00 $206.00 $266.00 $348.00 $287.00 $328.00 $378.00 $206.00 $266.00 $348.00 $266.00 $328.00 $348.00 $194.00 $410.00 $306.00 $348.00 $410.00 $451.00 $328.00 $368.00 $368.00 $266.00 $306.00 $389.00 $389.00 $287.00 $328.00 $204.00 $29.00 $29.00 $81.00 $121.00 $77.00 $91.00 $29.00

CDT © 2015 American Dental Association. All rights reserved.


MRA $81.00 $20.00 $79.00 $133.00 $102.00 $81.00 $71.00 $121.00 $204.00 $294.00 $83.00 BR $25.00 $20.00 $61.00 $81.00 $70.00 $75.00 $206.00 $204.00 $287.00 $102.00 $110.00 $53.00 $225.00 $274.00 $337.00 $102.00 $81.00 $163.00 $179.00 $194.00 $206.00 $77.00 $55.00 $102.00 $318.00 $204.00 $50.00 $102.00 $61.00 BR $114.00 $50.00 $223.00 $63.00 $265.00 $208.00 $328.00 $164.00

Part A, 156



MRA $195.00 $159.00 $96.00 $285.00 $328.00 $273.00 $155.00 $337.00 $208.00 $178.00 $194.00 $77.00 $55.00 $79.00 $55.00 $50.00 $69.00 $40.00 $27.00 BR $513.00 $513.00 $563.00 $563.00 $256.00 $259.00 $614.00 $614.00 $279.00 $27.00 $27.00 $27.00 $27.00 $61.00 $40.00 $61.00 $83.00 $22.00 $53.00 $61.00 $102.00 $305.00 $305.00 $204.00 $204.00 $163.00 $163.00 $121.00 $121.00 $102.00


MRA $102.00 $132.00 $163.00 $100.00 $163.00 $244.00 $244.00 $194.00 $204.00 $46.00 $50.00 $181.00 $36.00 $100.00 BR $81.00 $121.00 $2,052.00 $2,052.00 $2,770.00 $2,874.00 BR $1,334.00 $1,641.00 BR BR $1,026.00 $1,026.00 $1,384.00 BR $656.00 $1,539.00 $306.00 $1,539.00 $1,539.00 $563.00 BR $614.00 $614.00 BR $1,334.00 $780.00 $244.00 $163.00 $167.00 BR BR $574.00 $61.00 BR



MRA $219.00 BR $649.00 $3,016.00 $1,557.00 $769.00 $265.00 $303.00 $392.00 $418.00 $289.00 $379.00 $365.00 $359.00 $377.00 $513.00 $513.00 $513.00 $365.00 $359.00 $322.00 $326.00 $365.00 $346.00 $350.00 $414.00 $402.00 $447.00 $71.00 $229.00 $247.00 $264.00 BR $410.00 $287.00 $328.00 $451.00 $368.00 $410.00 $309.00 $410.00 $287.00 $368.00 $51.00 $195.00 $281.00 $155.00 $166.00 $172.00 $203.00

Part A, 157



MRA $110.00 $141.00 $139.00 $151.00 $170.00 $178.00 $203.00 $217.00 $141.00 $155.00 $151.00 $162.00 $410.00 $233.00 $348.00 $328.00 $356.00 $328.00 $410.00 $389.00 $320.00 $322.00 $324.00 $389.00 $287.00 $348.00 $30.00 $279.00 $40.00 $102.00 $155.00 $106.00 BR $45.00 $70.00 $111.00 $139.00 $147.00 $204.00 $81.00 $244.00 $147.00 $204.00 $121.00 $41.00 $106.00 $81.00 BR $133.00 $77.00


MRA $85.00 $108.00 $195.00 $410.00 $102.00 $100.00 $139.00 $205.00 $180.00 $291.00 $161.00 $247.00 $139.00 $179.00 $137.00 $195.00 $71.00 $174.00 $143.00 $147.00 $162.00 $2,545.00 $54.00 $121.00 $85.00 $121.00 $143.00 $266.00 $1,189.00 $984.00 $1,354.00 $820.00 $1,292.00 $780.00 $410.00 $779.00 $1,949.00 $1,415.00 $903.00 $1,580.00 $922.00 $1,334.00 $1,046.00 $533.00 $73.00 $2,504.00 $1,292.00 $110.00 $186.00 $1,764.00



MRA $1,682.00 $2,011.00 $2,052.00 BR $2,298.00 $614.00 $1,723.00 $81.00 BR $533.00 $584.00 $737.00 $789.00 $820.00 $758.00 $291.00 BR $73.00 $110.00 $163.00 $676.00 $841.00 $2,874.00 $2,914.00 $2,298.00 $2,319.00 $2,566.00 $2,566.00 $2,874.00 $4,186.00 $881.00 $922.00 $121.00 $137.00 $67.00 BR $169.00 $820.00 $306.00 $244.00 $340.00 $820.00 BR BR BR BR $451.00 $533.00 $718.00 $583.00

Part A, 158



MRA $676.00 $758.00 $1,867.00 $1,867.00 $1,949.00 $155.00 $179.00 $73.00 $54.00 $171.00 $71.00 $67.00 $104.00 BR $40.00 $14.00 $14.00 $13.00 $7.00 $18.00 $91.00 $41.00 $61.00 $46.00 $23.00 $41.00 BR $20.00 $10.00 $21.00 $21.00 $32.00 $34.00 $204.00 $58.00 $114.00 $46.00 $163.00 $83.00 $55.00 $113.00 $40.00 $50.00 BR $58.00 $114.00 $46.00 $163.00 $83.00 $55.00

Dental D-Code D9972 D9973 D9974 D9999

MRA $113.00 $40.00 $50.00 BR


Part A, 159


Injections J-Code J0120 J0130 J0190 J0200 J0205 J0207 J0210 J0215 J0256 J0280 J0282 J0285 J0287 J0288 J0289 J0290 J0295 J0300 J0330 J0350 J0360 J0380 J0390 J0395 J0456 J0470 J0475 J0476 J0500 J0515 J0520 J0583 J0585 J0587 J0592 J0595 J0600 J0610 J0620 J0630 J0636 J0637 J0640 J0670 J0690 J0692 J0694 J0696 J0697 J0698

MRA $12.00 BR $3.00 BR $38.00 BR $7.00 BR $101.00 $1.00 BR BR BR BR BR $2.00 $7.00 $2.00 $1.00 $2,408.00 $6.00 $1.00 $3.00 BR BR $11.00 $201.00 BR $3.00 $3.00 $5.00 BR $393.00 BR BR BR $6.00 $1.00 $3.00 $21.00 BR BR $22.00 BR $3.00 BR $10.00 $11.00 $6.00 $11.00

HCPCS © 2016


MRA $4.00 $3.00 $8.00 $6.00 $6.00 $3.00 BR BR $14.00 BR $1.00 $3.00 $32.00 $3.00 $18.00 $362.00 $10.00 $1.00 $3.00 $1.00 $2.00 $3.00 BR $1.00 $10.00 $35.00 $2.00 $1.00 $1.00 $1.00 BR $1.00 $9.00 $36.00 $1.00 $1.00 $31.00 $49.00 BR BR $1.00 BR BR $2.00 BR $6.00 $1.00 $33.00 $1.00 $68.00


MRA BR BR $12.00 $2.00 BR $36.00 $3.00 BR BR $10.00 $27.00 $69.00 BR $4.00 $28.00 $1.00 $1.00 BR $16.00 BR BR $23.00 $1.00 $5.00 $4.00 $94.00 BR BR BR BR $4.00 $10.00 $6.00 BR BR $76.00 BR $7.00 $4.00 $7.00 $11.00 $1.00 $411.00 $37.00 BR $2.00 $3.00 $8.00 BR $2.00

Part A, 160


Injections J-Code J2020 J2060 J2150 J2175 J2180 J2185 J2210 J2250 J2260 J2270 J2280 J2300 J2310 J2320 J2353 J2354 J2355 J2360 J2370 J2400 J2405 J2410 J2430 J2440 J2460 J2501 J2505 J2510 J2515 J2540 J2543 J2545 J2550 J2560 J2590 J2597 J2650 J2670 J2680 J2690 J2700 J2710 J2720 J2725 J2730 J2760 J2765 J2770 J2780 J2783 HCPCS © 2016

MRA BR $12.00 $3.00 $1.00 $3.00 BR $3.00 $2.00 $32.00 $1.00 BR $2.00 $3.00 $5.00 BR BR BR $2.00 $3.00 BR $6.00 $3.00 $189.00 $2.00 $1.00 BR BR $1.00 $1.00 $1.00 BR $105.00 $1.00 $5.00 $1.00 $20.00 $1.00 BR $16.00 $7.00 $2.00 $1.00 $1.00 $11.00 $29.00 $29.00 $2.00 BR BR BR


MRA $36.00 BR BR $3.00 $3.00 $115.00 $11.00 BR $5.00 $13.00 BR BR $1.00 BR BR BR $2.00 $2.00 $34.00 $4.00 $2.00 $2.00 $214.00 $1.00 $7.00 $2.00 $5.00 $1.00 $1.00 $1.00 $55.00 $5.00 $16.00 $72.00 $1.00 $52.00 $433.00 $9.00 $12.00 $1.00 BR BR $1.00 $2.00 BR $7.00 $1.00 $1.00 BR BR

Injections J-Code J3490 J3590 J7030 J7040 J7042 J7050 J7060 J7070 J7100 J7110 J7120 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7501 J7504 J7505 J7513 J7516 J7599 J7194 J7195 J7197 J7198 J7199 J7501 J7504 J7505 J7513 J7516 J7599

MRA BR BR $11.00 $10.00 $10.00 $10.00 $10.00 $11.00 $137.00 $93.00 $12.00 $241.00 BR $316.00 BR $120.00 BR $284.00 BR BR $98.00 $282.00 $576.00 BR BR BR $120.00 BR $284.00 BR BR $98.00 $282.00 $576.00 BR BR BR

Part A, 161


PART B SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES

2016 Edition

Page 162



Surgery CPT Code FUD 2003 MRA 10021 10022 10030 10035 10036 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11004 11005 11006 11008 11010 11011 11012 11042 11043 11044 11045 11046 11047 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400

0 0 0 0 ZZZ 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 0 0 ZZZ 10 0 0 0 0 0 ZZZ ZZZ ZZZ 0 0 0 0 ZZZ 10 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 10

$90.00 $92.00 ---------------------$54.00 $53.00 $133.00 $65.00 $203.00 $53.00 $169.00 $53.00 $45.00 $164.00 $45.00 $27.00 ----------------------------$348.00 $432.00 $597.00 $88.00 $210.00 $283.00 ---------------------$26.00 $35.00 $39.00 $78.00 $41.00 $66.00 $26.00 $59.00 $80.00 $96.00 $119.00 $61.00 $86.00 $100.00 $125.00 $75.00 $95.00 $110.00 $144.00 $81.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$174.00 $197.00 $1,084.00 $737.00 $639.00 $144.00 $165.00 $292.00 $250.00 $377.00 $212.00 $387.00 $229.00 $183.00 $351.00 $76.00 $30.00 $864.00 $1,178.00 $1,050.00 $414.00 $695.00 $759.00 $1,017.00 $163.00 $325.00 $451.00 $58.00 $106.00 $180.00 $66.00 $80.00 $91.00 $144.00 $47.00 $123.00 $27.00 $134.00 $167.00 $196.00 $217.00 $138.00 $169.00 $200.00 $210.00 $158.00 $157.00 $224.00 $260.00 $173.00

$184.00 $209.00 $1,163.00 $787.00 $683.00 $153.00 $174.00 $309.00 $267.00 $401.00 $225.00 $411.00 $243.00 $194.00 $376.00 $80.00 $32.00 $919.00 $1,261.00 $1,117.00 $444.00 $742.00 $812.00 $1,087.00 $173.00 $345.00 $479.00 $62.00 $113.00 $192.00 $69.00 $85.00 $96.00 $153.00 $49.00 $131.00 $29.00 $143.00 $177.00 $209.00 $231.00 $146.00 $180.00 $213.00 $223.00 $168.00 $166.00 $238.00 $277.00 $184.00

$191.00 $215.00 $1,193.00 $796.00 $689.00 $160.00 $179.00 $321.00 $274.00 $415.00 $231.00 $427.00 $251.00 $201.00 $396.00 $82.00 $33.00 $998.00 $1,387.00 $1,216.00 $489.00 $773.00 $851.00 $1,144.00 $178.00 $361.00 $505.00 $64.00 $120.00 $205.00 $70.00 $86.00 $98.00 $158.00 $52.00 $136.00 $30.00 $147.00 $182.00 $215.00 $239.00 $149.00 $185.00 $219.00 $228.00 $172.00 $173.00 $246.00 $287.00 $189.00

$102.00 $95.00 $253.00 $127.00 $64.00 $126.00 $138.00 $257.00 $147.00 $245.00 $147.00 $268.00 $169.00 $137.00 $260.00 $42.00 $21.00 $864.00 $1,178.00 $1,050.00 $414.00 $409.00 $442.00 $631.00 $89.00 $228.00 $340.00 $38.00 $83.00 $148.00 $23.00 $33.00 $43.00 $71.00 $37.00 $104.00 $24.00 $51.00 $78.00 $92.00 $109.00 $57.00 $76.00 $97.00 $107.00 $69.00 $96.00 $114.00 $147.00 $114.00

$107.00 $100.00 $271.00 $132.00 $67.00 $134.00 $145.00 $271.00 $156.00 $259.00 $155.00 $284.00 $179.00 $145.00 $279.00 $43.00 $22.00 $919.00 $1,261.00 $1,117.00 $444.00 $435.00 $471.00 $674.00 $94.00 $240.00 $360.00 $40.00 $88.00 $157.00 $24.00 $34.00 $44.00 $75.00 $39.00 $110.00 $26.00 $54.00 $82.00 $97.00 $115.00 $60.00 $79.00 $102.00 $112.00 $73.00 $101.00 $121.00 $155.00 $121.00

$114.00 $105.00 $298.00 $139.00 $70.00 $140.00 $150.00 $283.00 $163.00 $273.00 $161.00 $300.00 $187.00 $151.00 $298.00 $45.00 $23.00 $998.00 $1,387.00 $1,216.00 $489.00 $465.00 $510.00 $729.00 $99.00 $256.00 $386.00 $43.00 $95.00 $170.00 $25.00 $35.00 $46.00 $79.00 $41.00 $115.00 $27.00 $57.00 $87.00 $103.00 $122.00 $62.00 $84.00 $108.00 $118.00 $77.00 $108.00 $128.00 $165.00 $127.00

CPT only © 2015 American Medical Association. All rights reserved.

Part B, 163



10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 0 0 0 ZZZ 0 10 10 0

$114.00 $145.00 $178.00 $200.00 $246.00 $98.00 $92.00 $157.00 $163.00 $221.00 $303.00 $105.00 $102.00 $174.00 $221.00 $276.00 $344.00 $282.00 $366.00 $264.00 $351.00 $320.00 $391.00 $148.00 $180.00 $199.00 $226.00 $249.00 $315.00 $150.00 $191.00 $223.00 $259.00 $305.00 $373.00 $168.00 $227.00 $260.00 $305.00 $380.00 $494.00 $22.00 $32.00 $50.00 $62.00 $31.00 $41.00 $156.00 $234.00 $106.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$209.00 $232.00 $271.00 $308.00 $448.00 $171.00 $220.00 $246.00 $285.00 $331.00 $477.00 $188.00 $236.00 $265.00 $317.00 $400.00 $557.00 $539.00 $689.00 $525.00 $696.00 $585.00 $723.00 $269.00 $321.00 $348.00 $400.00 $445.00 $642.00 $272.00 $323.00 $361.00 $426.00 $481.00 $582.00 $281.00 $335.00 $383.00 $453.00 $560.00 $736.00 $19.00 $45.00 $63.00 $138.00 $50.00 $69.00 $251.00 $457.00 $186.00

$222.00 $247.00 $289.00 $329.00 $479.00 $181.00 $233.00 $262.00 $304.00 $352.00 $509.00 $200.00 $251.00 $282.00 $337.00 $425.00 $592.00 $577.00 $737.00 $562.00 $744.00 $626.00 $771.00 $286.00 $342.00 $371.00 $425.00 $474.00 $685.00 $290.00 $344.00 $384.00 $453.00 $512.00 $620.00 $299.00 $356.00 $408.00 $482.00 $596.00 $783.00 $20.00 $47.00 $66.00 $146.00 $53.00 $73.00 $266.00 $484.00 $197.00

$230.00 $257.00 $301.00 $344.00 $507.00 $186.00 $242.00 $272.00 $317.00 $369.00 $538.00 $205.00 $260.00 $293.00 $353.00 $446.00 $623.00 $606.00 $775.00 $587.00 $781.00 $657.00 $807.00 $296.00 $354.00 $385.00 $443.00 $495.00 $721.00 $300.00 $357.00 $399.00 $473.00 $536.00 $653.00 $309.00 $370.00 $424.00 $504.00 $624.00 $824.00 $21.00 $48.00 $68.00 $149.00 $54.00 $74.00 $271.00 $500.00 $201.00

$148.00 $164.00 $212.00 $235.00 $360.00 $116.00 $158.00 $194.00 $227.00 $260.00 $401.00 $146.00 $188.00 $209.00 $257.00 $329.00 $473.00 $367.00 $474.00 $349.00 $475.00 $409.00 $508.00 $171.00 $215.00 $236.00 $284.00 $313.00 $470.00 $174.00 $217.00 $249.00 $309.00 $351.00 $432.00 $180.00 $226.00 $268.00 $336.00 $416.00 $580.00 $11.00 $21.00 $36.00 $74.00 $29.00 $46.00 $198.00 $376.00 $112.00

$157.00 $174.00 $226.00 $250.00 $385.00 $123.00 $167.00 $206.00 $241.00 $277.00 $427.00 $155.00 $200.00 $222.00 $273.00 $349.00 $502.00 $392.00 $507.00 $373.00 $507.00 $437.00 $541.00 $182.00 $228.00 $250.00 $301.00 $333.00 $500.00 $185.00 $230.00 $264.00 $328.00 $372.00 $460.00 $191.00 $240.00 $284.00 $356.00 $441.00 $615.00 $11.00 $22.00 $37.00 $76.00 $30.00 $48.00 $209.00 $396.00 $117.00

$165.00 $183.00 $239.00 $266.00 $413.00 $128.00 $175.00 $216.00 $254.00 $293.00 $457.00 $160.00 $209.00 $233.00 $288.00 $370.00 $533.00 $420.00 $544.00 $398.00 $543.00 $467.00 $576.00 $191.00 $240.00 $264.00 $318.00 $353.00 $536.00 $195.00 $243.00 $278.00 $348.00 $396.00 $492.00 $201.00 $253.00 $300.00 $377.00 $469.00 $656.00 $12.00 $23.00 $39.00 $80.00 $31.00 $50.00 $214.00 $413.00 $121.00


Part B, 164



10 10 10 10 90 90 0 0 0 0 ZZZ 0 0 0 0 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

$131.00 $223.00 $65.00 $275.00 $496.00 $585.00 $33.00 $37.00 $147.00 $172.00 $40.00 $107.00 $114.00 $155.00 $165.00 $829.00 $632.00 $280.00 $123.00 $84.00 $98.00 $122.00 $165.00 $203.00 $339.00 $98.00 $141.00 $165.00 $207.00 $268.00 $316.00 $515.00 $211.00 $87.00 $93.00 $110.00 $148.00 $223.00 $356.00 $411.00 $116.00 $141.00 $176.00 $250.00 $341.00 $363.00 $126.00 $148.00 $223.00 $301.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$271.00 $393.00 $232.00 $395.00 $821.00 $996.00 $78.00 $99.00 $239.00 $280.00 $86.00 $103.00 $139.00 $186.00 $224.00 $1,359.00 $880.00 $657.00 $202.00 $125.00 $153.00 $181.00 $229.00 $272.00 $319.00 $154.00 $161.00 $189.00 $229.00 $292.00 $228.00 $258.00 $411.00 $238.00 $332.00 $425.00 $439.00 $539.00 $598.00 $679.00 $332.00 $407.00 $504.00 $568.00 $680.00 $737.00 $363.00 $414.00 $485.00 $508.00

$288.00 $415.00 $245.00 $423.00 $880.00 $1,066.00 $83.00 $105.00 $255.00 $298.00 $92.00 $109.00 $148.00 $198.00 $239.00 $1,446.00 $936.00 $701.00 $213.00 $133.00 $162.00 $192.00 $243.00 $288.00 $339.00 $163.00 $171.00 $200.00 $243.00 $310.00 $240.00 $272.00 $440.00 $254.00 $354.00 $452.00 $467.00 $575.00 $638.00 $724.00 $353.00 $433.00 $536.00 $605.00 $729.00 $788.00 $386.00 $441.00 $516.00 $540.00

$297.00 $426.00 $249.00 $446.00 $935.00 $1,132.00 $86.00 $109.00 $265.00 $311.00 $95.00 $111.00 $156.00 $208.00 $251.00 $1,523.00 $991.00 $725.00 $222.00 $137.00 $168.00 $200.00 $254.00 $302.00 $357.00 $169.00 $178.00 $209.00 $254.00 $325.00 $260.00 $295.00 $462.00 $268.00 $366.00 $468.00 $487.00 $599.00 $669.00 $761.00 $366.00 $450.00 $556.00 $629.00 $769.00 $829.00 $401.00 $458.00 $536.00 $562.00

$168.00 $264.00 $133.00 $271.00 $637.00 $840.00 $46.00 $70.00 $165.00 $195.00 $43.00 $73.00 $105.00 $142.00 $168.00 $1,359.00 $880.00 $455.00 $137.00 $65.00 $85.00 $107.00 $140.00 $172.00 $217.00 $81.00 $85.00 $110.00 $138.00 $189.00 $228.00 $258.00 $284.00 $205.00 $221.00 $281.00 $300.00 $350.00 $409.00 $479.00 $218.00 $290.00 $312.00 $392.00 $456.00 $506.00 $248.00 $295.00 $316.00 $324.00

$177.00 $276.00 $140.00 $290.00 $682.00 $899.00 $48.00 $74.00 $175.00 $207.00 $46.00 $77.00 $112.00 $150.00 $178.00 $1,446.00 $936.00 $485.00 $143.00 $68.00 $90.00 $113.00 $147.00 $181.00 $230.00 $85.00 $90.00 $116.00 $146.00 $199.00 $240.00 $272.00 $303.00 $218.00 $234.00 $298.00 $319.00 $372.00 $435.00 $510.00 $231.00 $308.00 $330.00 $416.00 $489.00 $541.00 $263.00 $313.00 $335.00 $343.00

$185.00 $287.00 $143.00 $313.00 $736.00 $964.00 $51.00 $79.00 $185.00 $220.00 $49.00 $79.00 $120.00 $159.00 $190.00 $1,523.00 $991.00 $508.00 $152.00 $72.00 $96.00 $120.00 $158.00 $195.00 $248.00 $91.00 $96.00 $124.00 $156.00 $215.00 $260.00 $295.00 $325.00 $231.00 $247.00 $314.00 $338.00 $396.00 $466.00 $546.00 $243.00 $324.00 $349.00 $440.00 $529.00 $581.00 $278.00 $330.00 $354.00 $364.00


Part B, 165



10 10 10 10 10 ZZZ 10 10 ZZZ 10 10 ZZZ 10 10 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ 90 0 ZZZ 0 ZZZ 0 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ ZZZ 90 ZZZ

$380.00 $487.00 $539.00 $178.00 $240.00 $89.00 $223.00 $348.00 $104.00 $252.00 $484.00 $154.00 $375.00 $542.00 $169.00 $655.00 $512.00 $695.00 $590.00 $818.00 $701.00 $936.00 $766.00 $1,330.00 --------------$734.00 -----------------------------------$349.00 $679.00 $146.00 ----------------------------$788.00 $235.00 ----------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$660.00 $772.00 $801.00 $470.00 $556.00 $172.00 $492.00 $601.00 $189.00 $542.00 $672.00 $255.00 $596.00 $717.00 $277.00 $1,179.00 $882.00 $1,140.00 $987.00 $1,238.00 $1,082.00 $1,341.00 $1,106.00 $1,442.00 $1,538.00 $327.00 $1,004.00 $494.00 $108.00 $569.00 $179.00 $361.00 $797.00 $1,230.00 $264.00 $1,154.00 $171.00 $1,182.00 $227.00 $1,218.00 $296.00 $963.00 $145.00 $1,208.00 $138.00 $1,019.00 $181.00 $223.00 $1,038.00 $234.00

$702.00 $822.00 $856.00 $500.00 $592.00 $184.00 $524.00 $640.00 $201.00 $577.00 $715.00 $271.00 $634.00 $763.00 $294.00 $1,255.00 $940.00 $1,215.00 $1,050.00 $1,316.00 $1,149.00 $1,425.00 $1,174.00 $1,532.00 $1,636.00 $347.00 $1,056.00 $526.00 $115.00 $603.00 $191.00 $386.00 $848.00 $1,313.00 $283.00 $1,225.00 $183.00 $1,252.00 $244.00 $1,296.00 $317.00 $1,027.00 $154.00 $1,280.00 $146.00 $1,092.00 $194.00 $239.00 $1,098.00 $250.00

$731.00 $858.00 $902.00 $519.00 $614.00 $193.00 $544.00 $664.00 $211.00 $600.00 $744.00 $284.00 $660.00 $796.00 $309.00 $1,342.00 $985.00 $1,278.00 $1,097.00 $1,379.00 $1,202.00 $1,491.00 $1,229.00 $1,602.00 $1,719.00 $373.00 $1,105.00 $552.00 $121.00 $629.00 $202.00 $402.00 $884.00 $1,389.00 $297.00 $1,294.00 $199.00 $1,318.00 $267.00 $1,364.00 $332.00 $1,084.00 $164.00 $1,342.00 $155.00 $1,180.00 $212.00 $261.00 $1,154.00 $272.00

$446.00 $549.00 $596.00 $300.00 $368.00 $110.00 $343.00 $390.00 $126.00 $364.00 $459.00 $193.00 $419.00 $509.00 $208.00 $1,179.00 $727.00 $950.00 $821.00 $1,041.00 $915.00 $1,128.00 $975.00 $1,207.00 $1,285.00 $327.00 $1,004.00 $333.00 $68.00 $395.00 $135.00 $189.00 $641.00 $1,044.00 $164.00 $1,016.00 $156.00 $1,042.00 $207.00 $1,018.00 $195.00 $821.00 $134.00 $1,069.00 $130.00 $939.00 $169.00 $210.00 $965.00 $223.00

$472.00 $583.00 $635.00 $317.00 $390.00 $117.00 $363.00 $413.00 $134.00 $385.00 $486.00 $204.00 $444.00 $539.00 $221.00 $1,255.00 $774.00 $1,012.00 $872.00 $1,105.00 $970.00 $1,196.00 $1,033.00 $1,279.00 $1,364.00 $347.00 $1,056.00 $354.00 $72.00 $417.00 $143.00 $201.00 $681.00 $1,113.00 $176.00 $1,076.00 $167.00 $1,102.00 $222.00 $1,081.00 $208.00 $875.00 $142.00 $1,130.00 $137.00 $1,007.00 $181.00 $225.00 $1,020.00 $238.00

$501.00 $618.00 $680.00 $336.00 $412.00 $125.00 $383.00 $437.00 $143.00 $408.00 $515.00 $217.00 $470.00 $571.00 $236.00 $1,342.00 $818.00 $1,074.00 $919.00 $1,167.00 $1,022.00 $1,261.00 $1,088.00 $1,349.00 $1,447.00 $373.00 $1,105.00 $379.00 $78.00 $442.00 $155.00 $216.00 $716.00 $1,188.00 $190.00 $1,145.00 $183.00 $1,167.00 $245.00 $1,149.00 $223.00 $931.00 $152.00 $1,193.00 $147.00 $1,094.00 $199.00 $247.00 $1,076.00 $260.00


Part B, 166



ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 ZZZ 90 90 90 90 10 ZZZ 90 90 90

-------$644.00 $126.00 $687.00 $114.00 $763.00 $334.00 $841.00 $207.00 --------------------------------------------------------$748.00 $721.00 $775.00 $457.00 $259.00 $320.00 $506.00 $362.00 $427.00 -------$1,465.00 $1,557.00 $1,862.00 $1,415.00 $913.00 $1,064.00 $2,892.00 $2,892.00 $2,884.00 $810.00 $674.00 $327.00 $475.00 -------$532.00 $420.00 $314.00 $340.00 $146.00 $27.00 $194.00 $360.00 $130.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$254.00 $1,184.00 $209.00 $1,093.00 $193.00 $1,328.00 $262.00 $1,440.00 $306.00 $199.00 $39.00 $426.00 $102.00 $210.00 $49.00 $461.00 $122.00 $1,304.00 $1,265.00 $1,304.00 $1,147.00 $449.00 $497.00 $618.00 $647.00 $711.00 $1,617.00 $1,837.00 $2,179.00 $1,904.00 $2,029.00 $1,452.00 $1,336.00 $3,408.00 $3,365.00 $3,371.00 $1,215.00 $972.00 $429.00 $706.00 $316.00 $1,189.00 $784.00 $889.00 $658.00 $342.00 $68.00 $638.00 $774.00 $614.00

$268.00 $1,261.00 $223.00 $1,164.00 $206.00 $1,412.00 $279.00 $1,528.00 $326.00 $211.00 $41.00 $454.00 $109.00 $222.00 $52.00 $490.00 $130.00 $1,390.00 $1,347.00 $1,386.00 $1,218.00 $480.00 $530.00 $659.00 $689.00 $757.00 $1,716.00 $1,945.00 $2,325.00 $2,028.00 $2,161.00 $1,543.00 $1,420.00 $3,614.00 $3,564.00 $3,572.00 $1,290.00 $1,033.00 $455.00 $751.00 $336.00 $1,262.00 $835.00 $948.00 $700.00 $363.00 $72.00 $681.00 $825.00 $657.00

$284.00 $1,325.00 $233.00 $1,217.00 $214.00 $1,480.00 $291.00 $1,597.00 $340.00 $219.00 $43.00 $479.00 $116.00 $229.00 $54.00 $516.00 $138.00 $1,465.00 $1,416.00 $1,455.00 $1,274.00 $494.00 $548.00 $683.00 $715.00 $788.00 $1,807.00 $2,035.00 $2,482.00 $2,151.00 $2,299.00 $1,616.00 $1,510.00 $3,854.00 $3,794.00 $3,806.00 $1,349.00 $1,092.00 $476.00 $788.00 $363.00 $1,310.00 $870.00 $976.00 $727.00 $373.00 $74.00 $695.00 $857.00 $671.00

$238.00 $976.00 $116.00 $890.00 $105.00 $1,159.00 $164.00 $1,243.00 $206.00 $124.00 $26.00 $299.00 $69.00 $139.00 $37.00 $332.00 $85.00 $1,071.00 $1,082.00 $1,113.00 $971.00 $295.00 $345.00 $468.00 $498.00 $550.00 $1,464.00 $1,616.00 $1,937.00 $1,666.00 $1,806.00 $1,238.00 $1,336.00 $3,408.00 $3,365.00 $3,371.00 $1,026.00 $972.00 $326.00 $521.00 $316.00 $912.00 $624.00 $636.00 $518.00 $196.00 $25.00 $350.00 $595.00 $372.00

$251.00 $1,038.00 $123.00 $946.00 $112.00 $1,231.00 $174.00 $1,317.00 $218.00 $131.00 $27.00 $318.00 $73.00 $145.00 $38.00 $351.00 $91.00 $1,140.00 $1,150.00 $1,182.00 $1,029.00 $314.00 $367.00 $498.00 $529.00 $585.00 $1,553.00 $1,709.00 $2,066.00 $1,773.00 $1,922.00 $1,313.00 $1,420.00 $3,614.00 $3,564.00 $3,572.00 $1,088.00 $1,033.00 $344.00 $553.00 $336.00 $964.00 $664.00 $677.00 $550.00 $206.00 $26.00 $372.00 $632.00 $397.00

$268.00 $1,102.00 $133.00 $999.00 $120.00 $1,297.00 $186.00 $1,385.00 $232.00 $139.00 $29.00 $343.00 $80.00 $153.00 $41.00 $377.00 $98.00 $1,214.00 $1,219.00 $1,250.00 $1,084.00 $328.00 $385.00 $522.00 $555.00 $615.00 $1,642.00 $1,798.00 $2,222.00 $1,896.00 $2,060.00 $1,386.00 $1,510.00 $3,854.00 $3,794.00 $3,806.00 $1,146.00 $1,092.00 $365.00 $589.00 $363.00 $1,011.00 $697.00 $704.00 $577.00 $216.00 $28.00 $385.00 $664.00 $410.00


Part B, 167



90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$232.00 $780.00 $556.00 $607.00 $499.00 $718.00 NC NC NC NC NC -------$926.00 $833.00 $837.00 $865.00 $721.00 $696.00 $600.00 $643.00 $1,187.00 $1,859.00 $3,099.00 $1,116.00 $63.00 $40.00 $35.00 $151.00 NC NC NC NC $571.00 $771.00 $638.00 $860.00 $1,064.00 $1,184.00 $1,032.00 $1,223.00 $318.00 $919.00 $954.00 $1,078.00 $1,737.00 $549.00 $872.00 $876.00 $1,013.00 $1,382.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$692.00 $1,066.00 $789.00 $852.00 $625.00 $851.00 BR BR BR BR BR $1,711.00 $1,333.00 $1,249.00 $1,286.00 $1,349.00 $1,108.00 $1,159.00 $830.00 $1,266.00 $1,465.00 $2,371.00 $3,851.00 $1,437.00 $125.00 $138.00 $69.00 $164.00 BR BR BR BR $883.00 $1,128.00 $1,010.00 $1,238.00 $1,360.00 $1,599.00 $1,305.00 $1,510.00 $1,026.00 $1,308.00 $1,289.00 $1,421.00 $2,388.00 $863.00 $1,269.00 $1,298.00 $1,439.00 $1,683.00


$762.00 $1,195.00 $853.00 $926.00 $681.00 $920.00 BR BR BR BR BR $1,947.00 $1,507.00 $1,410.00 $1,449.00 $1,526.00 $1,261.00 $1,314.00 $927.00 $1,421.00 $1,638.00 $2,692.00 $4,365.00 $1,566.00 $137.00 $150.00 $79.00 $188.00 BR BR BR BR $1,014.00 $1,270.00 $1,169.00 $1,418.00 $1,566.00 $1,831.00 $1,495.00 $1,725.00 $1,180.00 $1,489.00 $1,468.00 $1,616.00 $2,718.00 $990.00 $1,428.00 $1,462.00 $1,622.00 $1,921.00

$525.00 $1,066.00 $715.00 $770.00 $552.00 $767.00 BR BR BR BR BR $1,711.00 $1,333.00 $1,249.00 $1,286.00 $1,349.00 $1,108.00 $981.00 $830.00 $1,073.00 $1,465.00 $2,371.00 $3,851.00 $1,437.00 $61.00 $66.00 $69.00 $164.00 BR BR BR BR $883.00 $1,128.00 $1,010.00 $1,238.00 $1,360.00 $1,599.00 $1,305.00 $1,510.00 $1,026.00 $1,308.00 $1,289.00 $1,421.00 $2,388.00 $863.00 $1,269.00 $1,298.00 $1,439.00 $1,683.00


$582.00 $1,195.00 $774.00 $836.00 $602.00 $829.00 BR BR BR BR BR $1,947.00 $1,507.00 $1,410.00 $1,449.00 $1,526.00 $1,261.00 $1,122.00 $927.00 $1,213.00 $1,638.00 $2,692.00 $4,365.00 $1,566.00 $68.00 $73.00 $79.00 $188.00 BR BR BR BR $1,014.00 $1,270.00 $1,169.00 $1,418.00 $1,566.00 $1,831.00 $1,495.00 $1,725.00 $1,180.00 $1,489.00 $1,468.00 $1,616.00 $2,718.00 $990.00 $1,428.00 $1,462.00 $1,622.00 $1,921.00


Part B, 168



90 YYY 0 0 0 0 0 ZZZ 10 ZZZ 10 90 90 90 10 10 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 ZZZ ZZZ 10 10 0 YYY 0 ZZZ 90 0 0 ZZZ

$1,379.00 BR $53.00 $49.00 $67.00 $153.00 $341.00 $81.00 $60.00 $16.00 $233.00 $341.00 $648.00 $1,015.00 $55.00 $83.00 $27.00 $96.00 $117.00 $150.00 $172.00 $189.00 $225.00 $125.00 $143.00 $170.00 $195.00 $240.00 $281.00 $123.00 $165.00 $194.00 $239.00 $282.00 $373.00 -----------------------------------$37.00 $96.00 NC BR $74.00 $40.00 $288.00 $98.00 ---------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,708.00 -------$98.00 $114.00 $209.00 $264.00 $287.00 $120.00 $94.00 $8.00 $211.00 $482.00 $614.00 $909.00 $154.00 $183.00 $110.00 $133.00 $201.00 $246.00 $269.00 $288.00 $327.00 $211.00 $229.00 $262.00 $293.00 $346.00 $402.00 $197.00 $250.00 $288.00 $346.00 $396.00 $510.00 $930.00 $545.00 $868.00 $522.00 $113.00 $73.00 $182.00 BR -------$158.00 $39.00 $669.00 $231.00 $962.00 $790.00

$1,819.00 -------$103.00 $121.00 $222.00 $281.00 $302.00 $127.00 $100.00 $9.00 $224.00 $512.00 $652.00 $965.00 $164.00 $195.00 $117.00 $142.00 $214.00 $261.00 $286.00 $306.00 $348.00 $225.00 $243.00 $279.00 $311.00 $368.00 $427.00 $210.00 $266.00 $306.00 $367.00 $420.00 $541.00 $989.00 $580.00 $924.00 $556.00 $120.00 $77.00 $193.00 BR -------$168.00 $41.00 $717.00 $245.00 $1,026.00 $845.00

$1,944.00 -------$108.00 $125.00 $232.00 $294.00 $322.00 $137.00 $103.00 $9.00 $232.00 $533.00 $679.00 $1,011.00 $167.00 $200.00 $120.00 $147.00 $221.00 $271.00 $297.00 $318.00 $362.00 $233.00 $252.00 $290.00 $323.00 $383.00 $445.00 $217.00 $277.00 $319.00 $383.00 $438.00 $568.00 $1,028.00 $601.00 $958.00 $575.00 $125.00 $81.00 $202.00 BR -------$173.00 $43.00 $751.00 $251.00 $1,043.00 $854.00

$1,708.00 -------$67.00 $78.00 $161.00 $195.00 $287.00 $120.00 $76.00 $4.00 $144.00 $397.00 $500.00 $761.00 $99.00 $122.00 $53.00 $101.00 $132.00 $168.00 $187.00 $200.00 $234.00 $144.00 $160.00 $186.00 $209.00 $256.00 $308.00 $131.00 $180.00 $209.00 $261.00 $305.00 $410.00 $554.00 $295.00 $497.00 $273.00 $78.00 $71.00 $142.00 BR -------$64.00 $32.00 $445.00 $113.00 $249.00 $125.00

$1,819.00 -------$71.00 $82.00 $171.00 $207.00 $302.00 $127.00 $81.00 $4.00 $152.00 $420.00 $529.00 $807.00 $105.00 $129.00 $56.00 $107.00 $140.00 $178.00 $198.00 $211.00 $247.00 $152.00 $169.00 $197.00 $221.00 $271.00 $325.00 $139.00 $191.00 $221.00 $276.00 $322.00 $434.00 $586.00 $312.00 $525.00 $289.00 $82.00 $74.00 $151.00 BR -------$68.00 $34.00 $477.00 $118.00 $261.00 $131.00

$1,944.00 -------$75.00 $86.00 $181.00 $220.00 $322.00 $137.00 $84.00 $4.00 $160.00 $441.00 $556.00 $852.00 $108.00 $135.00 $59.00 $113.00 $147.00 $188.00 $209.00 $223.00 $261.00 $160.00 $178.00 $207.00 $233.00 $286.00 $344.00 $146.00 $201.00 $234.00 $292.00 $341.00 $460.00 $623.00 $331.00 $559.00 $307.00 $87.00 $78.00 $159.00 BR -------$72.00 $36.00 $511.00 $124.00 $277.00 $138.00


Part B, 169



0 ZZZ 0 ZZZ 0 10 0 90 90 90 90 ZZZ 90 90 90 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

----------------------------$117.00 $338.00 -------$406.00 $354.00 $429.00 $468.00 $201.00 $1,101.00 $1,561.00 $1,674.00 -------------------------------------------------------------------------------------------------------------------------------------$954.00 $1,313.00 $440.00 $656.00 $457.00 $569.00 $545.00 $963.00 $853.00 $755.00 $1,449.00 $1,667.00 $2,737.00 $1,676.00 $2,056.00 $2,444.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$929.00 $760.00 $1,422.00 $1,122.00 $214.00 $487.00 $2,937.00 $692.00 $648.00 $716.00 $795.00 $244.00 $1,779.00 $2,396.00 $2,623.00 $334.00 $233.00 $376.00 $282.00 $710.00 $621.00 $1,186.00 $953.00 $5,420.00 $143.00 $1,465.00 $750.00 $968.00 $1,335.00 $1,501.00 $844.00 $1,672.00 $1,778.00 $1,774.00 $1,121.00 $1,603.00 $720.00 $926.00 $717.00 $919.00 $1,456.00 $1,336.00 $1,175.00 $1,022.00 $2,170.00 $2,295.00 $4,028.00 $2,065.00 $2,611.00 $3,218.00

$991.00 $812.00 $1,519.00 $1,200.00 $229.00 $522.00 $3,143.00 $742.00 $695.00 $768.00 $853.00 $261.00 $1,907.00 $2,568.00 $2,810.00 $354.00 $248.00 $399.00 $301.00 $758.00 $665.00 $1,267.00 $1,019.00 $5,815.00 $153.00 $1,562.00 $804.00 $1,039.00 $1,432.00 $1,610.00 $905.00 $1,793.00 $1,909.00 $1,903.00 $1,193.00 $1,703.00 $772.00 $984.00 $763.00 $978.00 $1,548.00 $1,420.00 $1,252.00 $1,097.00 $2,309.00 $2,438.00 $4,278.00 $2,198.00 $2,773.00 $3,417.00

$1,006.00 $821.00 $1,538.00 $1,210.00 $241.00 $551.00 $3,167.00 $784.00 $732.00 $823.00 $917.00 $289.00 $2,070.00 $2,772.00 $3,037.00 $362.00 $252.00 $408.00 $306.00 $767.00 $670.00 $1,280.00 $1,027.00 $5,864.00 $169.00 $1,598.00 $852.00 $1,133.00 $1,564.00 $1,758.00 $978.00 $1,954.00 $2,081.00 $2,074.00 $1,273.00 $1,811.00 $836.00 $1,040.00 $809.00 $1,038.00 $1,644.00 $1,504.00 $1,315.00 $1,179.00 $2,436.00 $2,596.00 $4,566.00 $2,360.00 $2,954.00 $3,645.00

$233.00 $117.00 $274.00 $135.00 $105.00 $326.00 $284.00 $500.00 $453.00 $609.00 $678.00 $244.00 $1,779.00 $2,396.00 $2,623.00 $148.00 $75.00 $150.00 $76.00 $127.00 $64.00 $190.00 $95.00 $316.00 $143.00 $481.00 $603.00 $968.00 $1,335.00 $1,501.00 $844.00 $1,672.00 $1,778.00 $1,774.00 $1,121.00 $1,603.00 $720.00 $926.00 $717.00 $919.00 $1,456.00 $1,336.00 $975.00 $847.00 $2,170.00 $2,295.00 $4,028.00 $2,065.00 $2,611.00 $3,218.00

$244.00 $122.00 $287.00 $141.00 $112.00 $349.00 $297.00 $536.00 $486.00 $653.00 $728.00 $261.00 $1,907.00 $2,568.00 $2,810.00 $154.00 $78.00 $157.00 $80.00 $132.00 $67.00 $198.00 $98.00 $338.00 $153.00 $506.00 $646.00 $1,039.00 $1,432.00 $1,610.00 $905.00 $1,793.00 $1,909.00 $1,903.00 $1,193.00 $1,703.00 $772.00 $984.00 $763.00 $978.00 $1,548.00 $1,420.00 $1,037.00 $909.00 $2,309.00 $2,438.00 $4,278.00 $2,198.00 $2,773.00 $3,417.00

$257.00 $129.00 $302.00 $148.00 $124.00 $379.00 $312.00 $578.00 $523.00 $708.00 $791.00 $289.00 $2,070.00 $2,772.00 $3,037.00 $162.00 $82.00 $165.00 $84.00 $139.00 $70.00 $208.00 $103.00 $371.00 $169.00 $539.00 $694.00 $1,133.00 $1,564.00 $1,758.00 $978.00 $1,954.00 $2,081.00 $2,074.00 $1,273.00 $1,811.00 $836.00 $1,040.00 $809.00 $1,038.00 $1,644.00 $1,504.00 $1,100.00 $991.00 $2,436.00 $2,596.00 $4,566.00 $2,360.00 $2,954.00 $3,645.00


Part B, 170



90 90 90 90 0 YYY 10 10 10 10 10 90 0 0 0 0 0 0 10 10 10 10 0 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 10 0 90 90 90 10 10 90 90 90

$2,317.00 $662.00 $788.00 $780.00 $231.00 BR $267.00 $727.00 $261.00 $314.00 $405.00 $1,141.00 $134.00 $243.00 $119.00 $128.00 $215.00 $279.00 $364.00 $447.00 $511.00 $59.00 $60.00 $75.00 $331.00 $64.00 -------$40.00 $62.00 $62.00 $62.00 -------$41.00 -------$48.00 -------$49.00 -------$56.00 $94.00 $170.00 $320.00 $476.00 $559.00 $465.00 $105.00 $80.00 $332.00 $298.00 $516.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,991.00 $993.00 $1,136.00 $1,119.00 $390.00 -------$442.00 $903.00 $636.00 $698.00 $825.00 $1,320.00 $293.00 $413.00 $327.00 $236.00 $728.00 $226.00 $763.00 $578.00 $628.00 $147.00 $164.00 $287.00 $676.00 $110.00 $120.00 $83.00 $85.00 $78.00 $90.00 $480.00 $68.00 $102.00 $71.00 $113.00 $86.00 $130.00 $86.00 $345.00 $294.00 $374.00 $746.00 $617.00 $680.00 $149.00 $527.00 $879.00 $871.00 $1,632.00

$3,178.00 $1,056.00 $1,208.00 $1,190.00 $416.00 -------$470.00 $964.00 $682.00 $748.00 $880.00 $1,397.00 $315.00 $444.00 $349.00 $250.00 $777.00 $239.00 $810.00 $622.00 $676.00 $155.00 $175.00 $305.00 $722.00 $117.00 $128.00 $88.00 $90.00 $82.00 $95.00 $506.00 $71.00 $108.00 $75.00 $120.00 $91.00 $138.00 $91.00 $366.00 $312.00 $406.00 $810.00 $645.00 $727.00 $156.00 $563.00 $937.00 $928.00 $1,734.00

$3,395.00 $1,119.00 $1,281.00 $1,262.00 $430.00 -------$493.00 $1,048.00 $713.00 $785.00 $918.00 $1,487.00 $330.00 $470.00 $354.00 $255.00 $786.00 $254.00 $869.00 $678.00 $736.00 $160.00 $178.00 $316.00 $748.00 $124.00 $135.00 $92.00 $93.00 $85.00 $98.00 $538.00 $74.00 $112.00 $78.00 $125.00 $96.00 $144.00 $94.00 $378.00 $324.00 $455.00 $883.00 $662.00 $774.00 $160.00 $576.00 $979.00 $996.00 $1,847.00

$2,991.00 $993.00 $1,136.00 $1,119.00 $205.00 -------$341.00 $903.00 $310.00 $380.00 $510.00 $1,320.00 $142.00 $233.00 $86.00 $106.00 $158.00 $226.00 $763.00 $578.00 $628.00 $121.00 $56.00 $210.00 $363.00 $84.00 $97.00 $61.00 $62.00 $55.00 $63.00 $480.00 $52.00 $67.00 $54.00 $77.00 $67.00 $90.00 $61.00 $236.00 $226.00 $374.00 $746.00 $617.00 $680.00 $129.00 $212.00 $616.00 $871.00 $1,632.00

$3,178.00 $1,056.00 $1,208.00 $1,190.00 $217.00 -------$361.00 $964.00 $332.00 $407.00 $542.00 $1,397.00 $153.00 $251.00 $90.00 $111.00 $166.00 $239.00 $810.00 $622.00 $676.00 $127.00 $58.00 $223.00 $386.00 $89.00 $103.00 $64.00 $65.00 $58.00 $66.00 $506.00 $54.00 $70.00 $57.00 $81.00 $71.00 $95.00 $64.00 $249.00 $239.00 $406.00 $810.00 $645.00 $727.00 $135.00 $225.00 $655.00 $928.00 $1,734.00

$3,395.00 $1,119.00 $1,281.00 $1,262.00 $231.00 -------$384.00 $1,048.00 $363.00 $443.00 $579.00 $1,487.00 $168.00 $276.00 $94.00 $115.00 $173.00 $254.00 $869.00 $678.00 $736.00 $132.00 $61.00 $234.00 $412.00 $96.00 $110.00 $67.00 $68.00 $60.00 $69.00 $538.00 $57.00 $74.00 $60.00 $85.00 $76.00 $102.00 $68.00 $261.00 $251.00 $455.00 $883.00 $662.00 $774.00 $139.00 $236.00 $695.00 $996.00 $1,847.00


Part B, 171



90 90 90 0 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 0 ZZZ 0 ZZZ ZZZ 0 90 90 90 90 90 90 90 90 0 0 0 0 0 ZZZ YYY 90 90 90 90 90 90 90 90 90

$477.00 $421.00 --------------$3,363.00 $4,317.00 $5,324.00 $3,060.00 $2,511.00 $3,027.00 $3,920.00 $3,484.00 $454.00 $658.00 $338.00 $549.00 $460.00 $634.00 $583.00 $444.00 BR $156.00 BR $234.00 $257.00 $123.00 $3,332.00 $3,167.00 $3,074.00 $3,122.00 $3,716.00 $3,650.00 $3,420.00 $3,821.00 $266.00 $334.00 $19.00 ---------------------BR $854.00 ----------------------------$520.00 -------$546.00 $413.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$647.00 $607.00 $1,762.00 $2,707.00 $3,523.00 $4,866.00 $5,915.00 $3,053.00 $2,612.00 $3,001.00 $2,688.00 $3,558.00 $590.00 $422.00 $594.00 $696.00 $570.00 $881.00 $735.00 $626.00 -------$173.00 -------$254.00 $282.00 $352.00 $3,682.00 $3,926.00 $3,591.00 $3,083.00 $4,067.00 $4,352.00 $3,451.00 $3,875.00 $109.00 $265.00 $74.00 $4,165.00 $9,971.00 $219.00 -------$1,081.00 $494.00 $494.00 $741.00 $760.00 $1,036.00 $1,499.00 $1,292.00 $885.00

$687.00 $648.00 $1,877.00 $2,905.00 $3,712.00 $5,188.00 $6,296.00 $3,258.00 $2,771.00 $3,200.00 $2,868.00 $3,750.00 $630.00 $450.00 $629.00 $738.00 $604.00 $945.00 $783.00 $666.00 -------$188.00 -------$273.00 $306.00 $377.00 $3,904.00 $4,193.00 $3,782.00 $3,221.00 $4,305.00 $4,672.00 $3,607.00 $4,083.00 $116.00 $284.00 $79.00 $4,455.00 $10,688.00 $233.00 -------$1,145.00 $528.00 $528.00 $790.00 $810.00 $1,103.00 $1,595.00 $1,375.00 $943.00

$727.00 $680.00 $2,009.00 $2,914.00 $3,942.00 $5,588.00 $6,759.00 $3,514.00 $2,943.00 $3,450.00 $3,086.00 $3,981.00 $653.00 $484.00 $662.00 $778.00 $635.00 $1,009.00 $832.00 $708.00 -------$212.00 -------$302.00 $342.00 $386.00 $4,163.00 $4,533.00 $4,002.00 $3,369.00 $4,584.00 $5,101.00 $3,779.00 $4,338.00 $122.00 $310.00 $82.00 $4,498.00 $10,760.00 $253.00 -------$1,210.00 $550.00 $564.00 $829.00 $863.00 $1,174.00 $1,705.00 $1,443.00 $981.00

$647.00 $490.00 $1,762.00 $2,707.00 $3,523.00 $4,866.00 $5,915.00 $3,053.00 $2,612.00 $3,001.00 $2,688.00 $3,558.00 $280.00 $422.00 $594.00 $696.00 $570.00 $737.00 $735.00 $626.00 -------$173.00 -------$254.00 $282.00 $133.00 $3,682.00 $3,926.00 $3,591.00 $3,083.00 $4,067.00 $4,352.00 $3,451.00 $3,875.00 $74.00 $265.00 $47.00 $560.00 $599.00 $219.00 -------$1,081.00 $374.00 $494.00 $583.00 $760.00 $1,036.00 $1,499.00 $1,102.00 $724.00

$687.00 $523.00 $1,877.00 $2,905.00 $3,712.00 $5,188.00 $6,296.00 $3,258.00 $2,771.00 $3,200.00 $2,868.00 $3,750.00 $297.00 $450.00 $629.00 $738.00 $604.00 $790.00 $783.00 $666.00 -------$188.00 -------$273.00 $306.00 $142.00 $3,904.00 $4,193.00 $3,782.00 $3,221.00 $4,305.00 $4,672.00 $3,607.00 $4,083.00 $79.00 $284.00 $50.00 $587.00 $634.00 $233.00 -------$1,145.00 $399.00 $528.00 $621.00 $810.00 $1,103.00 $1,595.00 $1,171.00 $770.00

$727.00 $554.00 $2,009.00 $2,914.00 $3,942.00 $5,588.00 $6,759.00 $3,514.00 $2,943.00 $3,450.00 $3,086.00 $3,981.00 $319.00 $484.00 $662.00 $778.00 $635.00 $854.00 $832.00 $708.00 -------$212.00 -------$302.00 $342.00 $151.00 $4,163.00 $4,533.00 $4,002.00 $3,369.00 $4,584.00 $5,101.00 $3,779.00 $4,338.00 $84.00 $310.00 $53.00 $620.00 $676.00 $253.00 -------$1,210.00 $421.00 $564.00 $659.00 $863.00 $1,174.00 $1,705.00 $1,238.00 $807.00


Part B, 172



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 10 90 90 90 YYY 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$700.00 $496.00 $310.00 $315.00 $1,140.00 $227.00 $957.00 $1,313.00 $899.00 $1,109.00 $925.00 $1,051.00 $1,026.00 $972.00 $679.00 -------$1,192.00 $3,002.00 $2,086.00 $2,346.00 $2,138.00 $1,855.00 $1,802.00 $2,105.00 $801.00 $2,333.00 $2,217.00 BR BR $297.00 $371.00 $207.00 $500.00 $651.00 $700.00 $903.00 $656.00 $909.00 $797.00 $960.00 $1,168.00 $1,438.00 $1,527.00 $1,511.00 $1,513.00 $1,570.00 $1,639.00 $1,914.00 $2,264.00 $2,364.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,101.00 $747.00 $567.00 $576.00 $1,910.00 $752.00 $1,282.00 $1,800.00 $1,636.00 $1,944.00 $1,677.00 $1,780.00 $1,226.00 $1,161.00 $889.00 $554.00 $1,468.00 $3,682.00 $2,476.00 $2,778.00 $2,565.00 $2,421.00 $2,304.00 $2,650.00 $1,106.00 $2,738.00 $2,733.00 --------------$1,459.00 $1,151.00 $204.00 $939.00 $1,165.00 $953.00 $1,358.00 $4,269.00 $6,161.00 $1,112.00 $1,284.00 $1,387.00 $1,966.00 $2,062.00 $2,075.00 $2,326.00 $2,269.00 $2,567.00 $2,459.00 $2,949.00 $3,072.00

$1,171.00 $796.00 $604.00 $614.00 $2,027.00 $802.00 $1,358.00 $1,907.00 $1,740.00 $2,062.00 $1,784.00 $1,882.00 $1,300.00 $1,232.00 $941.00 $591.00 $1,561.00 $3,915.00 $2,633.00 $2,953.00 $2,728.00 $2,575.00 $2,451.00 $2,820.00 $1,177.00 $2,911.00 $2,907.00 --------------$1,571.00 $1,228.00 $217.00 $1,002.00 $1,242.00 $1,009.00 $1,446.00 $4,568.00 $6,597.00 $1,193.00 $1,352.00 $1,464.00 $2,088.00 $2,192.00 $2,200.00 $2,475.00 $2,398.00 $2,724.00 $2,601.00 $3,119.00 $3,270.00

$1,224.00 $830.00 $627.00 $638.00 $2,134.00 $835.00 $1,435.00 $2,020.00 $1,836.00 $2,192.00 $1,883.00 $1,994.00 $1,372.00 $1,300.00 $991.00 $615.00 $1,651.00 $4,142.00 $2,784.00 $3,119.00 $2,882.00 $2,717.00 $2,582.00 $2,973.00 $1,238.00 $3,080.00 $3,075.00 --------------$1,631.00 $1,271.00 $221.00 $1,037.00 $1,296.00 $1,057.00 $1,523.00 $4,647.00 $6,697.00 $1,287.00 $1,409.00 $1,545.00 $2,216.00 $2,329.00 $2,334.00 $2,647.00 $2,540.00 $2,897.00 $2,750.00 $3,280.00 $3,500.00

$926.00 $609.00 $430.00 $426.00 $1,697.00 $610.00 $1,282.00 $1,800.00 $1,636.00 $1,944.00 $1,677.00 $1,780.00 $1,226.00 $1,161.00 $889.00 $371.00 $1,244.00 $3,126.00 $2,080.00 $2,315.00 $2,130.00 $1,995.00 $1,851.00 $2,148.00 $842.00 $2,316.00 $2,311.00 --------------$731.00 $971.00 $65.00 $750.00 $981.00 $953.00 $1,358.00 $1,147.00 $1,311.00 $1,112.00 $1,284.00 $1,387.00 $1,966.00 $2,062.00 $2,075.00 $2,326.00 $2,269.00 $2,567.00 $2,459.00 $2,949.00 $3,072.00

$983.00 $648.00 $458.00 $454.00 $1,798.00 $649.00 $1,358.00 $1,907.00 $1,740.00 $2,062.00 $1,784.00 $1,882.00 $1,300.00 $1,232.00 $941.00 $394.00 $1,321.00 $3,318.00 $2,208.00 $2,456.00 $2,261.00 $2,119.00 $1,966.00 $2,281.00 $894.00 $2,459.00 $2,453.00 --------------$790.00 $1,036.00 $68.00 $800.00 $1,044.00 $1,009.00 $1,446.00 $1,218.00 $1,394.00 $1,193.00 $1,352.00 $1,464.00 $2,088.00 $2,192.00 $2,200.00 $2,475.00 $2,398.00 $2,724.00 $2,601.00 $3,119.00 $3,270.00

$1,035.00 $682.00 $480.00 $477.00 $1,904.00 $683.00 $1,435.00 $2,020.00 $1,836.00 $2,192.00 $1,883.00 $1,994.00 $1,372.00 $1,300.00 $991.00 $417.00 $1,411.00 $3,544.00 $2,358.00 $2,621.00 $2,414.00 $2,259.00 $2,096.00 $2,433.00 $954.00 $2,626.00 $2,620.00 --------------$848.00 $1,077.00 $72.00 $835.00 $1,098.00 $1,057.00 $1,523.00 $1,287.00 $1,478.00 $1,287.00 $1,409.00 $1,545.00 $2,216.00 $2,329.00 $2,334.00 $2,647.00 $2,540.00 $2,897.00 $2,750.00 $3,280.00 $3,500.00


Part B, 173



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 10

$2,640.00 $3,302.00 $3,500.00 $2,111.00 $2,604.00 $1,826.00 $2,035.00 $813.00 $2,570.00 $2,770.00 $3,150.00 $1,786.00 $1,331.00 $1,540.00 $1,360.00 $1,764.00 $1,268.00 $1,018.00 $1,112.00 $946.00 $576.00 $930.00 $970.00 $956.00 $707.00 $1,281.00 $1,207.00 $1,501.00 $1,062.00 $1,038.00 $1,010.00 $2,003.00 $1,023.00 $1,525.00 $1,459.00 $1,470.00 $1,372.00 $2,347.00 $2,361.00 $1,539.00 $1,946.00 $890.00 $963.00 $571.00 $360.00 $144.00 $384.00 BR $81.00 $180.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$3,149.00 $3,674.00 $4,658.00 $2,608.00 $3,125.00 $2,094.00 $2,260.00 $1,075.00 $2,858.00 $3,391.00 $3,139.00 $2,363.00 $1,783.00 $2,108.00 $1,954.00 $2,170.00 $1,708.00 $1,577.00 $1,716.00 $2,674.00 $1,161.00 $3,238.00 $5,706.00 $1,042.00 $1,038.00 $1,648.00 $1,509.00 $2,498.00 $1,553.00 $1,601.00 $1,277.00 $2,276.00 $1,613.00 $2,218.00 $2,026.00 $1,734.00 $2,021.00 $3,079.00 $2,842.00 $2,241.00 $2,536.00 $1,366.00 $1,217.00 $807.00 $541.00 $258.00 $621.00 -------$184.00 $391.00

$3,308.00 $3,874.00 $4,949.00 $2,726.00 $3,292.00 $2,194.00 $2,385.00 $1,143.00 $3,026.00 $3,601.00 $3,308.00 $2,509.00 $1,890.00 $2,235.00 $2,068.00 $2,303.00 $1,813.00 $1,675.00 $1,823.00 $2,854.00 $1,234.00 $3,461.00 $6,109.00 $1,102.00 $1,104.00 $1,751.00 $1,603.00 $2,654.00 $1,649.00 $1,699.00 $1,354.00 $2,408.00 $1,717.00 $2,360.00 $2,153.00 $1,823.00 $2,147.00 $3,250.00 $3,000.00 $2,353.00 $2,678.00 $1,444.00 $1,294.00 $850.00 $573.00 $274.00 $659.00 -------$196.00 $416.00

$3,460.00 $4,106.00 $5,268.00 $2,809.00 $3,455.00 $2,272.00 $2,522.00 $1,213.00 $3,229.00 $3,841.00 $3,516.00 $2,662.00 $2,009.00 $2,373.00 $2,176.00 $2,434.00 $1,913.00 $1,787.00 $1,924.00 $2,927.00 $1,281.00 $3,546.00 $6,205.00 $1,165.00 $1,150.00 $1,859.00 $1,702.00 $2,820.00 $1,735.00 $1,775.00 $1,437.00 $2,551.00 $1,803.00 $2,487.00 $2,274.00 $1,896.00 $2,265.00 $3,434.00 $3,168.00 $2,420.00 $2,825.00 $1,490.00 $1,373.00 $879.00 $594.00 $285.00 $688.00 -------$200.00 $428.00

$3,149.00 $3,674.00 $4,658.00 $2,608.00 $3,125.00 $2,094.00 $2,260.00 $1,075.00 $2,858.00 $3,391.00 $3,139.00 $2,363.00 $1,783.00 $2,108.00 $1,954.00 $2,170.00 $1,708.00 $1,577.00 $1,716.00 $1,220.00 $895.00 $1,272.00 $1,323.00 $1,042.00 $823.00 $1,648.00 $1,509.00 $2,498.00 $1,553.00 $1,294.00 $1,277.00 $2,276.00 $1,334.00 $1,900.00 $2,026.00 $1,734.00 $2,021.00 $3,079.00 $2,842.00 $2,241.00 $2,536.00 $1,037.00 $1,217.00 $807.00 $541.00 $258.00 $621.00 -------$40.00 $219.00

$3,308.00 $3,874.00 $4,949.00 $2,726.00 $3,292.00 $2,194.00 $2,385.00 $1,143.00 $3,026.00 $3,601.00 $3,308.00 $2,509.00 $1,890.00 $2,235.00 $2,068.00 $2,303.00 $1,813.00 $1,675.00 $1,823.00 $1,293.00 $949.00 $1,352.00 $1,406.00 $1,102.00 $873.00 $1,751.00 $1,603.00 $2,654.00 $1,649.00 $1,370.00 $1,354.00 $2,408.00 $1,417.00 $2,019.00 $2,153.00 $1,823.00 $2,147.00 $3,250.00 $3,000.00 $2,353.00 $2,678.00 $1,091.00 $1,294.00 $850.00 $573.00 $274.00 $659.00 -------$42.00 $232.00

$3,460.00 $4,106.00 $5,268.00 $2,809.00 $3,455.00 $2,272.00 $2,522.00 $1,213.00 $3,229.00 $3,841.00 $3,516.00 $2,662.00 $2,009.00 $2,373.00 $2,176.00 $2,434.00 $1,913.00 $1,787.00 $1,924.00 $1,362.00 $995.00 $1,431.00 $1,489.00 $1,165.00 $918.00 $1,859.00 $1,702.00 $2,820.00 $1,735.00 $1,445.00 $1,437.00 $2,551.00 $1,502.00 $2,145.00 $2,274.00 $1,896.00 $2,265.00 $3,434.00 $3,168.00 $2,420.00 $2,825.00 $1,136.00 $1,373.00 $879.00 $594.00 $285.00 $688.00 -------$45.00 $243.00


Part B, 174



10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0

$235.00 $348.00 $639.00 $852.00 $478.00 $300.00 $550.00 $689.00 $907.00 $1,043.00 $1,450.00 $738.00 $917.00 $1,048.00 $1,286.00 $295.00 $372.00 $590.00 $1,239.00 $1,386.00 $810.00 $812.00 $958.00 $920.00 $1,384.00 $143.00 $313.00 $852.00 $736.00 $1,007.00 $528.00 $761.00 $890.00 $598.00 $744.00 $1,981.00 $1,404.00 $2,045.00 $308.00 $533.00 $325.00 $498.00 $195.00 $902.00 $905.00 $769.00 $1,012.00 $923.00 $1,331.00 $82.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$363.00 $676.00 $813.00 $1,050.00 $924.00 $574.00 $1,035.00 $1,105.00 $1,096.00 $1,740.00 $2,037.00 $1,164.00 $1,314.00 $1,644.00 $1,762.00 $614.00 $717.00 $782.00 $1,627.00 $1,693.00 $988.00 $1,009.00 $1,035.00 $1,149.00 $1,461.00 $273.00 $628.00 $754.00 $935.00 $1,276.00 $1,080.00 $979.00 $1,190.00 $1,066.00 $952.00 $2,536.00 $1,847.00 $3,096.00 $822.00 $1,106.00 $882.00 $1,091.00 $843.00 $1,306.00 $863.00 $3,021.00 $3,212.00 $1,401.00 $1,767.00 $139.00

$387.00 $720.00 $865.00 $1,114.00 $982.00 $612.00 $1,104.00 $1,172.00 $1,156.00 $1,852.00 $2,155.00 $1,236.00 $1,393.00 $1,749.00 $1,871.00 $652.00 $763.00 $830.00 $1,725.00 $1,790.00 $1,045.00 $1,072.00 $1,096.00 $1,214.00 $1,551.00 $291.00 $669.00 $799.00 $990.00 $1,354.00 $1,152.00 $1,040.00 $1,264.00 $1,135.00 $1,010.00 $2,691.00 $1,953.00 $3,330.00 $879.00 $1,180.00 $942.00 $1,164.00 $901.00 $1,393.00 $918.00 $3,230.00 $3,433.00 $1,489.00 $1,876.00 $148.00

$398.00 $747.00 $901.00 $1,168.00 $1,023.00 $634.00 $1,153.00 $1,220.00 $1,216.00 $1,948.00 $2,279.00 $1,291.00 $1,458.00 $1,842.00 $1,990.00 $678.00 $795.00 $875.00 $1,830.00 $1,898.00 $1,097.00 $1,136.00 $1,154.00 $1,274.00 $1,646.00 $301.00 $693.00 $842.00 $1,041.00 $1,438.00 $1,195.00 $1,096.00 $1,336.00 $1,186.00 $1,063.00 $2,863.00 $2,068.00 $3,636.00 $903.00 $1,224.00 $968.00 $1,203.00 $918.00 $1,439.00 $968.00 $3,296.00 $3,511.00 $1,577.00 $1,990.00 $152.00

$196.00 $676.00 $813.00 $1,050.00 $924.00 $425.00 $1,035.00 $1,105.00 $1,096.00 $1,740.00 $2,037.00 $950.00 $1,314.00 $1,644.00 $1,762.00 $466.00 $549.00 $782.00 $1,627.00 $1,693.00 $988.00 $1,009.00 $1,035.00 $1,149.00 $1,461.00 $223.00 $415.00 $754.00 $935.00 $1,276.00 $917.00 $979.00 $1,190.00 $1,066.00 $952.00 $2,536.00 $1,847.00 $3,096.00 $671.00 $907.00 $710.00 $921.00 $502.00 $1,125.00 $863.00 $1,357.00 $1,516.00 $1,401.00 $1,767.00 $47.00

$208.00 $720.00 $865.00 $1,114.00 $982.00 $452.00 $1,104.00 $1,172.00 $1,156.00 $1,852.00 $2,155.00 $1,006.00 $1,393.00 $1,749.00 $1,871.00 $493.00 $583.00 $830.00 $1,725.00 $1,790.00 $1,045.00 $1,072.00 $1,096.00 $1,214.00 $1,551.00 $238.00 $440.00 $799.00 $990.00 $1,354.00 $977.00 $1,040.00 $1,264.00 $1,135.00 $1,010.00 $2,691.00 $1,953.00 $3,330.00 $716.00 $966.00 $758.00 $982.00 $536.00 $1,199.00 $918.00 $1,445.00 $1,614.00 $1,489.00 $1,876.00 $50.00

$219.00 $747.00 $901.00 $1,168.00 $1,023.00 $473.00 $1,153.00 $1,220.00 $1,216.00 $1,948.00 $2,279.00 $1,060.00 $1,458.00 $1,842.00 $1,990.00 $519.00 $614.00 $875.00 $1,830.00 $1,898.00 $1,097.00 $1,136.00 $1,154.00 $1,274.00 $1,646.00 $248.00 $463.00 $842.00 $1,041.00 $1,438.00 $1,019.00 $1,096.00 $1,336.00 $1,186.00 $1,063.00 $2,863.00 $2,068.00 $3,636.00 $740.00 $1,010.00 $783.00 $1,021.00 $551.00 $1,244.00 $968.00 $1,506.00 $1,687.00 $1,577.00 $1,990.00 $53.00


Part B, 175



90 90 90 90 YYY 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 90 YYY 10 90 90 90 90 90 90 90 90 90 90 90

$318.00 $865.00 $500.00 $372.00 BR $315.00 $612.00 $534.00 $165.00 --------------$337.00 $431.00 $794.00 -------$631.00 $828.00 $938.00 $1,042.00 $689.00 $686.00 $1,455.00 $1,514.00 -------$576.00 $746.00 $523.00 $588.00 $1,387.00 BR BR $1,009.00 ---------------------$143.00 $810.00 BR $165.00 $371.00 $403.00 ---------------------$1,280.00 ---------------------$850.00 $862.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,003.00 $1,340.00 $1,012.00 $1,048.00 -------$648.00 $786.00 $661.00 $372.00 $659.00 $1,082.00 $595.00 $777.00 $1,414.00 $1,996.00 $816.00 $1,815.00 $926.00 $1,120.00 $744.00 $793.00 $1,794.00 $1,803.00 $1,463.00 $555.00 $831.00 $662.00 $785.00 $1,527.00 --------------$1,023.00 $919.00 $1,102.00 $1,438.00 $200.00 $799.00 -------$364.00 $641.00 $680.00 $694.00 $979.00 $1,092.00 $1,518.00 $2,095.00 $1,416.00 $1,369.00 $1,301.00 $1,262.00

$1,071.00 $1,425.00 $1,076.00 $1,119.00 -------$692.00 $843.00 $710.00 $396.00 $706.00 $1,156.00 $636.00 $828.00 $1,508.00 $2,130.00 $873.00 $1,986.00 $992.00 $1,196.00 $795.00 $849.00 $1,915.00 $1,930.00 $1,548.00 $593.00 $890.00 $707.00 $845.00 $1,631.00 --------------$1,096.00 $984.00 $1,181.00 $1,538.00 $214.00 $856.00 -------$388.00 $686.00 $728.00 $744.00 $1,049.00 $1,169.00 $1,624.00 $2,241.00 $1,528.00 $1,473.00 $1,410.00 $1,360.00

$1,104.00 $1,512.00 $1,116.00 $1,152.00 -------$724.00 $914.00 $769.00 $409.00 $763.00 $1,249.00 $669.00 $886.00 $1,624.00 $2,304.00 $934.00 $2,235.00 $1,086.00 $1,299.00 $858.00 $912.00 $2,072.00 $2,104.00 $1,636.00 $647.00 $980.00 $756.00 $921.00 $1,779.00 --------------$1,199.00 $1,082.00 $1,299.00 $1,691.00 $223.00 $925.00 -------$401.00 $724.00 $770.00 $806.00 $1,138.00 $1,269.00 $1,760.00 $2,435.00 $1,670.00 $1,605.00 $1,549.00 $1,481.00

$843.00 $1,340.00 $1,012.00 $876.00 -------$468.00 $786.00 $661.00 $229.00 $659.00 $1,082.00 $447.00 $777.00 $1,414.00 $1,996.00 $816.00 $1,815.00 $926.00 $1,120.00 $744.00 $793.00 $1,794.00 $1,803.00 $1,463.00 $555.00 $831.00 $662.00 $785.00 $1,527.00 --------------$1,023.00 $919.00 $1,102.00 $1,438.00 $205.00 $799.00 -------$232.00 $517.00 $535.00 $694.00 $979.00 $1,092.00 $1,518.00 $2,095.00 $1,416.00 $1,369.00 $1,301.00 $1,262.00

$899.00 $1,425.00 $1,076.00 $935.00 -------$500.00 $843.00 $710.00 $243.00 $706.00 $1,156.00 $478.00 $828.00 $1,508.00 $2,130.00 $873.00 $1,986.00 $992.00 $1,196.00 $795.00 $849.00 $1,915.00 $1,930.00 $1,548.00 $593.00 $890.00 $707.00 $845.00 $1,631.00 --------------$1,096.00 $984.00 $1,181.00 $1,538.00 $219.00 $856.00 -------$247.00 $553.00 $572.00 $744.00 $1,049.00 $1,169.00 $1,624.00 $2,241.00 $1,528.00 $1,473.00 $1,410.00 $1,360.00

$933.00 $1,512.00 $1,116.00 $968.00 -------$531.00 $914.00 $769.00 $255.00 $763.00 $1,249.00 $510.00 $886.00 $1,624.00 $2,304.00 $934.00 $2,235.00 $1,086.00 $1,299.00 $858.00 $912.00 $2,072.00 $2,104.00 $1,636.00 $647.00 $980.00 $756.00 $921.00 $1,779.00 --------------$1,199.00 $1,082.00 $1,299.00 $1,691.00 $229.00 $925.00 -------$260.00 $591.00 $613.00 $806.00 $1,138.00 $1,269.00 $1,760.00 $2,435.00 $1,670.00 $1,605.00 $1,549.00 $1,481.00


Part B, 176



90 ZZZ 90 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 10 10 10 ZZZ 10 10 ZZZ 10 ZZZ 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90

$781.00 $198.00 $889.00 $1,090.00 $1,062.00 $195.00 ---------------------$1,892.00 $1,668.00 $819.00 $492.00 $1,801.00 $1,604.00 $1,731.00 $488.00 $213.00 $272.00 $711.00 $1,755.00 $1,983.00 $1,407.00 $1,710.00 $1,660.00 $391.00 $174.00 -----------------------------------------------------------------------------$2,271.00 --------------$1,727.00 $2,054.00 $1,907.00 $473.00 -------$1,895.00 $1,960.00 $1,567.00 $1,494.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,160.00 $211.00 $1,568.00 $1,455.00 $1,460.00 $217.00 $3,677.00 $3,596.00 $884.00 $2,684.00 $2,207.00 $2,215.00 $551.00 $2,389.00 $2,297.00 $2,353.00 $550.00 $274.00 $447.00 $1,290.00 $2,508.00 $2,796.00 $2,157.00 $2,255.00 $2,261.00 $433.00 $187.00 $2,459.00 $2,432.00 $1,364.00 $10,089.00 $10,073.00 $6,095.00 $3,291.00 $2,722.00 $2,684.00 $2,463.00 $548.00 $3,037.00 $2,602.00 $615.00 $1,892.00 $2,511.00 $2,309.00 $503.00 $2,698.00 $2,403.00 $2,290.00 $1,944.00 $1,898.00

$1,239.00 $228.00 $1,698.00 $1,555.00 $1,560.00 $235.00 $3,969.00 $3,874.00 $953.00 $2,904.00 $2,375.00 $2,385.00 $593.00 $2,575.00 $2,453.00 $2,526.00 $593.00 $292.00 $478.00 $1,387.00 $2,740.00 $3,063.00 $2,334.00 $2,450.00 $2,450.00 $470.00 $200.00 $2,623.00 $2,596.00 $1,457.00 $10,819.00 $10,802.00 $6,538.00 $3,521.00 $2,915.00 $2,905.00 $2,642.00 $591.00 $3,332.00 $2,825.00 $668.00 $2,049.00 $2,713.00 $2,484.00 $543.00 $2,883.00 $2,618.00 $2,493.00 $2,111.00 $2,055.00

$1,330.00 $251.00 $1,871.00 $1,670.00 $1,674.00 $262.00 $4,380.00 $4,261.00 $1,056.00 $3,204.00 $2,592.00 $2,604.00 $656.00 $2,822.00 $2,643.00 $2,747.00 $656.00 $308.00 $510.00 $1,489.00 $3,080.00 $3,462.00 $2,570.00 $2,724.00 $2,708.00 $527.00 $214.00 $2,668.00 $2,638.00 $1,484.00 $10,915.00 $10,893.00 $6,589.00 $3,563.00 $2,939.00 $3,212.00 $2,875.00 $655.00 $3,773.00 $3,147.00 $750.00 $2,265.00 $2,995.00 $2,723.00 $603.00 $3,118.00 $2,924.00 $2,781.00 $2,338.00 $2,264.00

$1,160.00 $211.00 $1,568.00 $1,455.00 $1,460.00 $217.00 $3,677.00 $3,596.00 $884.00 $2,684.00 $2,207.00 $2,215.00 $551.00 $2,389.00 $2,297.00 $2,353.00 $550.00 $250.00 $414.00 $1,139.00 $2,508.00 $2,796.00 $2,157.00 $2,255.00 $2,261.00 $433.00 $187.00 $664.00 $623.00 $312.00 $800.00 $745.00 $340.00 $514.00 $235.00 $2,684.00 $2,463.00 $548.00 $3,037.00 $2,602.00 $615.00 $1,892.00 $2,511.00 $2,309.00 $503.00 $2,698.00 $2,403.00 $2,290.00 $1,944.00 $1,898.00

$1,239.00 $228.00 $1,698.00 $1,555.00 $1,560.00 $235.00 $3,969.00 $3,874.00 $953.00 $2,904.00 $2,375.00 $2,385.00 $593.00 $2,575.00 $2,453.00 $2,526.00 $593.00 $267.00 $443.00 $1,224.00 $2,740.00 $3,063.00 $2,334.00 $2,450.00 $2,450.00 $470.00 $200.00 $698.00 $655.00 $329.00 $852.00 $793.00 $363.00 $541.00 $247.00 $2,905.00 $2,642.00 $591.00 $3,332.00 $2,825.00 $668.00 $2,049.00 $2,713.00 $2,484.00 $543.00 $2,883.00 $2,618.00 $2,493.00 $2,111.00 $2,055.00

$1,330.00 $251.00 $1,871.00 $1,670.00 $1,674.00 $262.00 $4,380.00 $4,261.00 $1,056.00 $3,204.00 $2,592.00 $2,604.00 $656.00 $2,822.00 $2,643.00 $2,747.00 $656.00 $283.00 $475.00 $1,326.00 $3,080.00 $3,462.00 $2,570.00 $2,724.00 $2,708.00 $527.00 $214.00 $737.00 $692.00 $352.00 $919.00 $855.00 $396.00 $574.00 $263.00 $3,212.00 $2,875.00 $655.00 $3,773.00 $3,147.00 $750.00 $2,265.00 $2,995.00 $2,723.00 $603.00 $3,118.00 $2,924.00 $2,781.00 $2,338.00 $2,264.00


Part B, 177



90 ZZZ 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 ZZZ 0 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 YYY 90 90 90 90 90 90 YYY 90 90 10 10 90 90

$1,861.00 $530.00 $1,201.00 $442.00 --------------$1,960.00 $2,633.00 $2,951.00 $2,157.00 $2,356.00 $2,675.00 $2,701.00 $2,968.00 $1,176.00 $943.00 BR $2,352.00 $1,028.00 $1,277.00 $1,853.00 $999.00 $1,077.00 $529.00 $2,235.00 $872.00 $600.00 $854.00 $1,193.00 -------------------------------------------------BR $446.00 -----------------------------------BR $447.00 $807.00 $323.00 $185.00 $861.00 $898.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,387.00 $599.00 $2,374.00 $494.00 $2,799.00 $761.00 $2,016.00 $3,138.00 $3,634.00 $2,764.00 $3,050.00 $3,675.00 $3,223.00 $4,270.00 $1,213.00 $1,164.00 -------$1,167.00 $1,246.00 $1,493.00 $1,124.00 $1,168.00 $1,258.00 $546.00 $1,955.00 $1,080.00 $624.00 $1,034.00 $1,670.00 $2,450.00 $2,994.00 $772.00 $3,004.00 $3,041.00 $3,162.00 $3,035.00 -------$834.00 $985.00 $631.00 $649.00 $1,557.00 $1,978.00 -------$828.00 $1,003.00 $625.00 $599.00 $986.00 $1,049.00

$2,574.00 $649.00 $2,578.00 $537.00 $3,027.00 $824.00 $2,169.00 $3,371.00 $3,906.00 $2,984.00 $3,284.00 $4,019.00 $3,441.00 $4,687.00 $1,308.00 $1,260.00 -------$1,263.00 $1,348.00 $1,607.00 $1,221.00 $1,268.00 $1,355.00 $588.00 $2,111.00 $1,165.00 $676.00 $1,115.00 $1,808.00 $2,650.00 $3,273.00 $838.00 $3,206.00 $3,304.00 $3,458.00 $3,240.00 -------$894.00 $1,055.00 $677.00 $695.00 $1,667.00 $2,117.00 -------$885.00 $1,070.00 $669.00 $641.00 $1,052.00 $1,120.00

$2,830.00 $724.00 $2,866.00 $603.00 $3,347.00 $920.00 $2,367.00 $3,684.00 $4,278.00 $3,289.00 $3,610.00 $4,534.00 $3,721.00 $5,329.00 $1,431.00 $1,405.00 -------$1,409.00 $1,502.00 $1,774.00 $1,370.00 $1,422.00 $1,499.00 $649.00 $2,325.00 $1,275.00 $755.00 $1,218.00 $1,998.00 $2,932.00 $3,685.00 $940.00 $3,475.00 $3,718.00 $3,903.00 $3,498.00 -------$969.00 $1,146.00 $717.00 $754.00 $1,813.00 $2,306.00 -------$921.00 $1,143.00 $698.00 $663.00 $1,124.00 $1,197.00

$2,387.00 $599.00 $2,374.00 $494.00 $2,799.00 $761.00 $2,016.00 $3,138.00 $3,634.00 $2,764.00 $3,050.00 $3,675.00 $3,223.00 $4,270.00 $1,213.00 $1,164.00 -------$1,167.00 $1,246.00 $1,493.00 $1,124.00 $1,168.00 $1,258.00 $546.00 $1,955.00 $1,080.00 $624.00 $1,034.00 $1,670.00 $2,450.00 $2,994.00 $772.00 $3,004.00 $3,041.00 $3,162.00 $3,035.00 -------$834.00 $985.00 $486.00 $649.00 $1,557.00 $1,978.00 -------$537.00 $1,003.00 $374.00 $318.00 $986.00 $1,049.00

$2,574.00 $649.00 $2,578.00 $537.00 $3,027.00 $824.00 $2,169.00 $3,371.00 $3,906.00 $2,984.00 $3,284.00 $4,019.00 $3,441.00 $4,687.00 $1,308.00 $1,260.00 -------$1,263.00 $1,348.00 $1,607.00 $1,221.00 $1,268.00 $1,355.00 $588.00 $2,111.00 $1,165.00 $676.00 $1,115.00 $1,808.00 $2,650.00 $3,273.00 $838.00 $3,206.00 $3,304.00 $3,458.00 $3,240.00 -------$894.00 $1,055.00 $521.00 $695.00 $1,667.00 $2,117.00 -------$573.00 $1,070.00 $399.00 $340.00 $1,052.00 $1,120.00

$2,830.00 $724.00 $2,866.00 $603.00 $3,347.00 $920.00 $2,367.00 $3,684.00 $4,278.00 $3,289.00 $3,610.00 $4,534.00 $3,721.00 $5,329.00 $1,431.00 $1,405.00 -------$1,409.00 $1,502.00 $1,774.00 $1,370.00 $1,422.00 $1,499.00 $649.00 $2,325.00 $1,275.00 $755.00 $1,218.00 $1,998.00 $2,932.00 $3,685.00 $940.00 $3,475.00 $3,718.00 $3,903.00 $3,498.00 -------$969.00 $1,146.00 $560.00 $754.00 $1,813.00 $2,306.00 -------$608.00 $1,143.00 $427.00 $361.00 $1,124.00 $1,197.00


Part B, 178



90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90

$708.00 $171.00 $302.00 --------------$247.00 $613.00 $1,228.00 -------$616.00 $583.00 $814.00 $581.00 $851.00 $645.00 $865.00 $722.00 $597.00 $889.00 $704.00 $755.00 $945.00 $794.00 $645.00 $638.00 $882.00 $566.00 $865.00 $962.00 $656.00 $902.00 $1,095.00 $1,095.00 $1,307.00 $59.00 ---------------------$74.00 $1,366.00 $1,403.00 $1,196.00 $799.00 $977.00 $1,119.00 $1,229.00 $622.00 $1,276.00 $884.00 $906.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$830.00 $310.00 $788.00 $618.00 $1,022.00 $669.00 $792.00 $1,694.00 $2,125.00 $723.00 $660.00 $928.00 $714.00 $959.00 $847.00 $1,035.00 $886.00 $778.00 $1,014.00 $902.00 $955.00 $1,159.00 $985.00 $808.00 $822.00 $1,092.00 $973.00 $947.00 $1,070.00 $827.00 $1,099.00 $2,197.00 $2,615.00 $2,861.00 $337.00 $656.00 $1,579.00 $1,881.00 $182.00 $1,882.00 $1,674.00 $1,424.00 $910.00 $1,120.00 $1,200.00 $1,245.00 $1,015.00 $1,416.00 $1,087.00 $1,103.00

$886.00 $329.00 $844.00 $662.00 $1,093.00 $717.00 $847.00 $1,812.00 $2,271.00 $772.00 $706.00 $990.00 $763.00 $1,023.00 $904.00 $1,106.00 $947.00 $831.00 $1,084.00 $962.00 $1,018.00 $1,238.00 $1,051.00 $863.00 $878.00 $1,165.00 $1,040.00 $1,011.00 $1,142.00 $882.00 $1,173.00 $2,349.00 $2,790.00 $3,050.00 $359.00 $698.00 $1,685.00 $2,008.00 $193.00 $2,007.00 $1,787.00 $1,520.00 $970.00 $1,192.00 $1,281.00 $1,329.00 $1,084.00 $1,511.00 $1,159.00 $1,177.00

$949.00 $344.00 $880.00 $715.00 $1,180.00 $754.00 $911.00 $1,963.00 $2,461.00 $822.00 $753.00 $1,057.00 $813.00 $1,091.00 $962.00 $1,185.00 $1,010.00 $889.00 $1,160.00 $1,027.00 $1,085.00 $1,326.00 $1,122.00 $922.00 $935.00 $1,244.00 $1,115.00 $1,077.00 $1,221.00 $942.00 $1,256.00 $2,542.00 $3,008.00 $3,284.00 $372.00 $741.00 $1,808.00 $2,158.00 $197.00 $2,151.00 $1,921.00 $1,633.00 $1,035.00 $1,271.00 $1,371.00 $1,422.00 $1,159.00 $1,618.00 $1,237.00 $1,259.00

$830.00 $243.00 $517.00 $618.00 $1,022.00 $477.00 $792.00 $1,694.00 $2,125.00 $723.00 $660.00 $928.00 $714.00 $959.00 $847.00 $1,035.00 $886.00 $778.00 $1,014.00 $902.00 $955.00 $1,159.00 $985.00 $808.00 $822.00 $1,092.00 $973.00 $947.00 $1,070.00 $827.00 $1,099.00 $2,197.00 $2,615.00 $2,861.00 $217.00 $656.00 $1,579.00 $1,881.00 $74.00 $1,882.00 $1,674.00 $1,424.00 $910.00 $1,120.00 $1,200.00 $1,245.00 $1,015.00 $1,416.00 $1,087.00 $1,103.00

$886.00 $258.00 $553.00 $662.00 $1,093.00 $510.00 $847.00 $1,812.00 $2,271.00 $772.00 $706.00 $990.00 $763.00 $1,023.00 $904.00 $1,106.00 $947.00 $831.00 $1,084.00 $962.00 $1,018.00 $1,238.00 $1,051.00 $863.00 $878.00 $1,165.00 $1,040.00 $1,011.00 $1,142.00 $882.00 $1,173.00 $2,349.00 $2,790.00 $3,050.00 $231.00 $698.00 $1,685.00 $2,008.00 $77.00 $2,007.00 $1,787.00 $1,520.00 $970.00 $1,192.00 $1,281.00 $1,329.00 $1,084.00 $1,511.00 $1,159.00 $1,177.00

$949.00 $273.00 $589.00 $715.00 $1,180.00 $546.00 $911.00 $1,963.00 $2,461.00 $822.00 $753.00 $1,057.00 $813.00 $1,091.00 $962.00 $1,185.00 $1,010.00 $889.00 $1,160.00 $1,027.00 $1,085.00 $1,326.00 $1,122.00 $922.00 $935.00 $1,244.00 $1,115.00 $1,077.00 $1,221.00 $942.00 $1,256.00 $2,542.00 $3,008.00 $3,284.00 $243.00 $741.00 $1,808.00 $2,158.00 $81.00 $2,151.00 $1,921.00 $1,633.00 $1,035.00 $1,271.00 $1,371.00 $1,422.00 $1,159.00 $1,618.00 $1,237.00 $1,259.00


Part B, 179



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 YYY 10

$1,210.00 $1,340.00 $1,364.00 $1,383.00 $1,398.00 $1,332.00 $1,540.00 $1,570.00 --------------$926.00 $1,181.00 $1,038.00 $1,251.00 $148.00 $293.00 $688.00 $205.00 $320.00 $659.00 $713.00 $148.00 $148.00 $701.00 $753.00 $88.00 $306.00 $809.00 $318.00 $511.00 $900.00 $1,895.00 $286.00 $422.00 $712.00 $296.00 $374.00 $712.00 $440.00 $759.00 $550.00 $1,064.00 $237.00 $1,346.00 $1,368.00 $1,561.00 $1,300.00 $497.00 BR $71.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,384.00 $1,464.00 $1,601.00 $1,554.00 $1,628.00 $1,634.00 $1,766.00 $2,142.00 $2,394.00 $2,587.00 $1,201.00 $1,398.00 $1,229.00 $1,484.00 $311.00 $505.00 $1,049.00 $320.00 $537.00 $801.00 $900.00 $319.00 $482.00 $819.00 $953.00 $331.00 $572.00 $1,436.00 $463.00 $664.00 $1,292.00 $1,823.00 $383.00 $542.00 $1,139.00 $445.00 $578.00 $845.00 $608.00 $1,280.00 $791.00 $1,357.00 $286.00 $1,505.00 $1,850.00 $2,042.00 $1,650.00 $679.00 -------$502.00

$1,476.00 $1,561.00 $1,709.00 $1,657.00 $1,735.00 $1,741.00 $1,883.00 $2,282.00 $2,552.00 $2,757.00 $1,283.00 $1,491.00 $1,309.00 $1,585.00 $331.00 $539.00 $1,119.00 $342.00 $573.00 $854.00 $958.00 $340.00 $513.00 $872.00 $1,016.00 $353.00 $611.00 $1,531.00 $494.00 $708.00 $1,378.00 $1,944.00 $409.00 $578.00 $1,215.00 $473.00 $617.00 $901.00 $649.00 $1,365.00 $844.00 $1,447.00 $305.00 $1,607.00 $1,972.00 $2,180.00 $1,762.00 $725.00 -------$537.00

$1,583.00 $1,674.00 $1,838.00 $1,779.00 $1,858.00 $1,861.00 $2,021.00 $2,451.00 $2,743.00 $2,966.00 $1,377.00 $1,599.00 $1,398.00 $1,702.00 $347.00 $568.00 $1,195.00 $359.00 $603.00 $911.00 $1,019.00 $356.00 $534.00 $928.00 $1,084.00 $371.00 $646.00 $1,641.00 $517.00 $747.00 $1,474.00 $2,087.00 $428.00 $609.00 $1,297.00 $495.00 $653.00 $960.00 $684.00 $1,461.00 $892.00 $1,549.00 $326.00 $1,727.00 $2,112.00 $2,345.00 $1,894.00 $772.00 -------$562.00

$1,384.00 $1,464.00 $1,601.00 $1,554.00 $1,628.00 $1,634.00 $1,766.00 $2,142.00 $2,394.00 $2,587.00 $1,201.00 $1,398.00 $1,229.00 $1,484.00 $316.00 $479.00 $1,049.00 $325.00 $498.00 $801.00 $900.00 $325.00 $440.00 $819.00 $953.00 $340.00 $538.00 $1,436.00 $438.00 $611.00 $1,292.00 $1,823.00 $365.00 $506.00 $1,139.00 $411.00 $578.00 $845.00 $568.00 $1,280.00 $724.00 $1,357.00 $286.00 $1,505.00 $1,850.00 $2,042.00 $1,650.00 $679.00 -------$316.00

$1,476.00 $1,561.00 $1,709.00 $1,657.00 $1,735.00 $1,741.00 $1,883.00 $2,282.00 $2,552.00 $2,757.00 $1,283.00 $1,491.00 $1,309.00 $1,585.00 $337.00 $511.00 $1,119.00 $347.00 $532.00 $854.00 $958.00 $346.00 $468.00 $872.00 $1,016.00 $364.00 $575.00 $1,531.00 $467.00 $652.00 $1,378.00 $1,944.00 $390.00 $540.00 $1,215.00 $436.00 $617.00 $901.00 $606.00 $1,365.00 $772.00 $1,447.00 $305.00 $1,607.00 $1,972.00 $2,180.00 $1,762.00 $725.00 -------$337.00

$1,583.00 $1,674.00 $1,838.00 $1,779.00 $1,858.00 $1,861.00 $2,021.00 $2,451.00 $2,743.00 $2,966.00 $1,377.00 $1,599.00 $1,398.00 $1,702.00 $353.00 $540.00 $1,195.00 $364.00 $561.00 $911.00 $1,019.00 $362.00 $489.00 $928.00 $1,084.00 $382.00 $609.00 $1,641.00 $490.00 $691.00 $1,474.00 $2,087.00 $409.00 $571.00 $1,297.00 $458.00 $653.00 $960.00 $642.00 $1,461.00 $821.00 $1,549.00 $326.00 $1,727.00 $2,112.00 $2,345.00 $1,894.00 $772.00 -------$362.00


Part B, 180



10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 90 90 90 90 90 90 90 90 90 90 90 90

$62.00 $630.00 $550.00 $793.00 $166.00 $461.00 --------------$349.00 $529.00 $1,058.00 -------$467.00 $591.00 $755.00 $360.00 $724.00 $898.00 $1,037.00 $595.00 $663.00 $731.00 $595.00 $966.00 $720.00 $697.00 $963.00 $592.00 $703.00 $1,224.00 $1,265.00 $829.00 $1,019.00 $533.00 $564.00 $58.00 $444.00 $89.00 $352.00 $869.00 $579.00 $511.00 $944.00 $845.00 $927.00 $487.00 $697.00 $702.00 $950.00 $643.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$403.00 $733.00 $690.00 $1,028.00 $362.00 $890.00 $597.00 $1,018.00 $699.00 $794.00 $1,529.00 $1,955.00 $605.00 $725.00 $896.00 $504.00 $842.00 $1,078.00 $1,263.00 $766.00 $889.00 $946.00 $736.00 $1,090.00 $904.00 $976.00 $1,019.00 $862.00 $901.00 $1,712.00 $2,296.00 $1,932.00 $1,236.00 $1,855.00 $1,067.00 $293.00 $776.00 $224.00 $596.00 $1,092.00 $835.00 $682.00 $1,142.00 $1,048.00 $1,150.00 $890.00 $890.00 $1,083.00 $1,131.00 $1,024.00

$431.00 $782.00 $736.00 $1,095.00 $386.00 $953.00 $639.00 $1,089.00 $748.00 $849.00 $1,635.00 $2,089.00 $647.00 $773.00 $955.00 $538.00 $898.00 $1,151.00 $1,349.00 $817.00 $946.00 $1,011.00 $785.00 $1,163.00 $960.00 $1,043.00 $1,087.00 $921.00 $962.00 $1,824.00 $2,451.00 $2,049.00 $1,319.00 $1,977.00 $1,140.00 $312.00 $831.00 $238.00 $637.00 $1,163.00 $889.00 $726.00 $1,220.00 $1,120.00 $1,228.00 $951.00 $949.00 $1,156.00 $1,206.00 $1,092.00

$445.00 $831.00 $783.00 $1,168.00 $400.00 $1,000.00 $689.00 $1,174.00 $785.00 $911.00 $1,770.00 $2,261.00 $689.00 $822.00 $1,018.00 $569.00 $956.00 $1,234.00 $1,448.00 $869.00 $1,004.00 $1,081.00 $835.00 $1,245.00 $1,013.00 $1,112.00 $1,161.00 $985.00 $1,024.00 $1,946.00 $2,642.00 $2,176.00 $1,415.00 $2,122.00 $1,221.00 $324.00 $871.00 $243.00 $668.00 $1,242.00 $943.00 $770.00 $1,309.00 $1,200.00 $1,318.00 $1,016.00 $1,012.00 $1,229.00 $1,288.00 $1,161.00

$230.00 $733.00 $690.00 $1,028.00 $242.00 $607.00 $597.00 $1,018.00 $481.00 $794.00 $1,529.00 $1,955.00 $605.00 $725.00 $896.00 $504.00 $842.00 $1,078.00 $1,263.00 $766.00 $889.00 $946.00 $736.00 $1,090.00 $904.00 $976.00 $1,019.00 $862.00 $901.00 $1,712.00 $2,296.00 $1,932.00 $1,236.00 $1,855.00 $1,067.00 $202.00 $526.00 $101.00 $596.00 $1,092.00 $835.00 $682.00 $1,142.00 $1,048.00 $1,150.00 $890.00 $890.00 $1,083.00 $1,131.00 $1,024.00

$245.00 $782.00 $736.00 $1,095.00 $257.00 $649.00 $639.00 $1,089.00 $515.00 $849.00 $1,635.00 $2,089.00 $647.00 $773.00 $955.00 $538.00 $898.00 $1,151.00 $1,349.00 $817.00 $946.00 $1,011.00 $785.00 $1,163.00 $960.00 $1,043.00 $1,087.00 $921.00 $962.00 $1,824.00 $2,451.00 $2,049.00 $1,319.00 $1,977.00 $1,140.00 $215.00 $562.00 $105.00 $637.00 $1,163.00 $889.00 $726.00 $1,220.00 $1,120.00 $1,228.00 $951.00 $949.00 $1,156.00 $1,206.00 $1,092.00

$259.00 $831.00 $783.00 $1,168.00 $271.00 $695.00 $689.00 $1,174.00 $551.00 $911.00 $1,770.00 $2,261.00 $689.00 $822.00 $1,018.00 $569.00 $956.00 $1,234.00 $1,448.00 $869.00 $1,004.00 $1,081.00 $835.00 $1,245.00 $1,013.00 $1,112.00 $1,161.00 $985.00 $1,024.00 $1,946.00 $2,642.00 $2,176.00 $1,415.00 $2,122.00 $1,221.00 $227.00 $601.00 $110.00 $668.00 $1,242.00 $943.00 $770.00 $1,309.00 $1,200.00 $1,318.00 $1,016.00 $1,012.00 $1,229.00 $1,288.00 $1,161.00


Part B, 181



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$971.00 $643.00 $971.00 ---------------------$1,125.00 $1,215.00 $1,269.00 $1,663.00 $747.00 $850.00 --------------$991.00 $1,319.00 $1,265.00 $1,209.00 $1,260.00 $774.00 $742.00 $1,076.00 $288.00 $574.00 $1,018.00 $1,029.00 $88.00 $671.00 $850.00 $946.00 $1,273.00 $266.00 $526.00 $705.00 $872.00 $295.00 $575.00 $964.00 $773.00 $1,314.00 $1,278.00 $360.00 $371.00 $836.00 $560.00 $1,329.00 $262.00 $436.00 $749.00 $905.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,603.00 $1,021.00 $1,598.00 $618.00 $756.00 $958.00 $1,295.00 $1,462.00 $1,556.00 $2,136.00 $927.00 $989.00 $2,288.00 $2,620.00 $1,191.00 $1,551.00 $1,428.00 $1,546.00 $1,573.00 $822.00 $950.00 $1,266.00 $508.00 $714.00 $1,279.00 $1,258.00 $541.00 $883.00 $1,082.00 $1,358.00 $1,520.00 $453.00 $760.00 $1,042.00 $1,062.00 $481.00 $780.00 $1,218.00 $1,168.00 $1,586.00 $1,581.00 $519.00 $678.00 $1,038.00 $794.00 $978.00 $369.00 $620.00 $945.00 $1,066.00

$1,712.00 $1,089.00 $1,704.00 $657.00 $806.00 $1,021.00 $1,381.00 $1,561.00 $1,662.00 $2,275.00 $990.00 $1,055.00 $2,443.00 $2,791.00 $1,271.00 $1,656.00 $1,520.00 $1,648.00 $1,678.00 $868.00 $1,017.00 $1,351.00 $543.00 $762.00 $1,364.00 $1,343.00 $578.00 $942.00 $1,156.00 $1,449.00 $1,621.00 $483.00 $813.00 $1,114.00 $1,132.00 $513.00 $833.00 $1,300.00 $1,246.00 $1,690.00 $1,683.00 $551.00 $724.00 $1,107.00 $846.00 $1,043.00 $394.00 $660.00 $1,008.00 $1,137.00

$1,835.00 $1,159.00 $1,822.00 $693.00 $856.00 $1,088.00 $1,478.00 $1,677.00 $1,786.00 $2,440.00 $1,059.00 $1,125.00 $2,632.00 $2,996.00 $1,360.00 $1,779.00 $1,618.00 $1,766.00 $1,794.00 $916.00 $1,090.00 $1,446.00 $568.00 $804.00 $1,458.00 $1,439.00 $606.00 $998.00 $1,235.00 $1,551.00 $1,737.00 $504.00 $860.00 $1,188.00 $1,207.00 $536.00 $881.00 $1,389.00 $1,325.00 $1,811.00 $1,801.00 $579.00 $769.00 $1,183.00 $898.00 $1,112.00 $411.00 $693.00 $1,072.00 $1,213.00

$1,603.00 $1,021.00 $1,598.00 $618.00 $756.00 $958.00 $1,295.00 $1,462.00 $1,556.00 $2,136.00 $927.00 $989.00 $2,288.00 $2,620.00 $1,191.00 $1,551.00 $1,428.00 $1,546.00 $1,573.00 $822.00 $950.00 $1,266.00 $465.00 $650.00 $1,279.00 $1,258.00 $492.00 $819.00 $1,082.00 $1,358.00 $1,520.00 $408.00 $702.00 $1,042.00 $1,062.00 $434.00 $720.00 $1,218.00 $1,168.00 $1,586.00 $1,581.00 $478.00 $678.00 $1,038.00 $794.00 $978.00 $341.00 $567.00 $945.00 $1,066.00

$1,712.00 $1,089.00 $1,704.00 $657.00 $806.00 $1,021.00 $1,381.00 $1,561.00 $1,662.00 $2,275.00 $990.00 $1,055.00 $2,443.00 $2,791.00 $1,271.00 $1,656.00 $1,520.00 $1,648.00 $1,678.00 $868.00 $1,017.00 $1,351.00 $496.00 $693.00 $1,364.00 $1,343.00 $525.00 $874.00 $1,156.00 $1,449.00 $1,621.00 $434.00 $750.00 $1,114.00 $1,132.00 $463.00 $768.00 $1,300.00 $1,246.00 $1,690.00 $1,683.00 $507.00 $724.00 $1,107.00 $846.00 $1,043.00 $363.00 $604.00 $1,008.00 $1,137.00

$1,835.00 $1,159.00 $1,822.00 $693.00 $856.00 $1,088.00 $1,478.00 $1,677.00 $1,786.00 $2,440.00 $1,059.00 $1,125.00 $2,632.00 $2,996.00 $1,360.00 $1,779.00 $1,618.00 $1,766.00 $1,794.00 $916.00 $1,090.00 $1,446.00 $521.00 $734.00 $1,458.00 $1,439.00 $554.00 $930.00 $1,235.00 $1,551.00 $1,737.00 $455.00 $797.00 $1,188.00 $1,207.00 $486.00 $816.00 $1,389.00 $1,325.00 $1,811.00 $1,801.00 $535.00 $769.00 $1,183.00 $898.00 $1,112.00 $380.00 $637.00 $1,072.00 $1,213.00


Part B, 182



90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$263.00 $490.00 $819.00 $984.00 $1,181.00 $858.00 $851.00 $661.00 $928.00 $1,063.00 $1,327.00 BR BR $381.00 $294.00 $594.00 $1,040.00 $683.00 $1,104.00 $417.00 $266.00 $794.00 $654.00 $164.00 $322.00 --------------$352.00 $544.00 $957.00 -------$562.00 $420.00 $492.00 $635.00 $600.00 -------$403.00 $356.00 $441.00 $837.00 $807.00 $466.00 $653.00 $712.00 $803.00 $781.00 $502.00 $631.00 $546.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$412.00 $648.00 $949.00 $1,212.00 $1,431.00 $1,069.00 $1,067.00 $800.00 $1,125.00 $1,168.00 $1,637.00 --------------$482.00 $490.00 $822.00 $1,593.00 $1,128.00 $1,765.00 $749.00 $518.00 $839.00 $815.00 $358.00 $518.00 $624.00 $775.00 $679.00 $749.00 $1,300.00 $1,714.00 $649.00 $497.00 $580.00 $695.00 $888.00 $776.00 $493.00 $460.00 $557.00 $1,098.00 $864.00 $549.00 $713.00 $717.00 $844.00 $863.00 $642.00 $802.00 $709.00

$440.00 $691.00 $1,013.00 $1,295.00 $1,524.00 $1,141.00 $1,139.00 $855.00 $1,202.00 $1,233.00 $1,752.00 --------------$515.00 $523.00 $877.00 $1,699.00 $1,204.00 $1,879.00 $801.00 $553.00 $894.00 $868.00 $381.00 $554.00 $667.00 $827.00 $726.00 $799.00 $1,389.00 $1,831.00 $692.00 $531.00 $618.00 $740.00 $946.00 $826.00 $527.00 $491.00 $594.00 $1,170.00 $920.00 $585.00 $760.00 $765.00 $900.00 $922.00 $683.00 $857.00 $758.00

$460.00 $728.00 $1,078.00 $1,388.00 $1,630.00 $1,223.00 $1,219.00 $915.00 $1,291.00 $1,305.00 $1,898.00 --------------$542.00 $551.00 $921.00 $1,805.00 $1,290.00 $2,013.00 $844.00 $586.00 $951.00 $923.00 $394.00 $587.00 $717.00 $883.00 $760.00 $851.00 $1,497.00 $1,976.00 $734.00 $564.00 $654.00 $784.00 $1,002.00 $875.00 $558.00 $518.00 $630.00 $1,243.00 $974.00 $618.00 $804.00 $811.00 $961.00 $984.00 $721.00 $913.00 $808.00

$374.00 $594.00 $949.00 $1,212.00 $1,431.00 $1,069.00 $1,067.00 $800.00 $1,125.00 $1,168.00 $1,637.00 --------------$482.00 $490.00 $822.00 $1,593.00 $1,128.00 $1,765.00 $749.00 $518.00 $839.00 $815.00 $235.00 $518.00 $624.00 $775.00 $460.00 $749.00 $1,300.00 $1,714.00 $649.00 $497.00 $580.00 $695.00 $888.00 $776.00 $493.00 $460.00 $557.00 $1,098.00 $864.00 $549.00 $713.00 $717.00 $844.00 $863.00 $642.00 $802.00 $709.00

$399.00 $634.00 $1,013.00 $1,295.00 $1,524.00 $1,141.00 $1,139.00 $855.00 $1,202.00 $1,233.00 $1,752.00 --------------$515.00 $523.00 $877.00 $1,699.00 $1,204.00 $1,879.00 $801.00 $553.00 $894.00 $868.00 $250.00 $554.00 $667.00 $827.00 $492.00 $799.00 $1,389.00 $1,831.00 $692.00 $531.00 $618.00 $740.00 $946.00 $826.00 $527.00 $491.00 $594.00 $1,170.00 $920.00 $585.00 $760.00 $765.00 $900.00 $922.00 $683.00 $857.00 $758.00

$419.00 $670.00 $1,078.00 $1,388.00 $1,630.00 $1,223.00 $1,219.00 $915.00 $1,291.00 $1,305.00 $1,898.00 --------------$542.00 $551.00 $921.00 $1,805.00 $1,290.00 $2,013.00 $844.00 $586.00 $951.00 $923.00 $262.00 $587.00 $717.00 $883.00 $524.00 $851.00 $1,497.00 $1,976.00 $734.00 $564.00 $654.00 $784.00 $1,002.00 $875.00 $558.00 $518.00 $630.00 $1,243.00 $974.00 $618.00 $804.00 $811.00 $961.00 $984.00 $721.00 $913.00 $808.00


Part B, 183



90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$713.00 $720.00 $771.00 $1,085.00 $561.00 $817.00 $531.00 $567.00 $72.00 $236.00 $616.00 $933.00 $348.00 $728.00 $809.00 $998.00 $549.00 $613.00 $887.00 $620.00 $670.00 $436.00 $562.00 $592.00 $757.00 $865.00 $968.00 $1,004.00 $1,203.00 $834.00 $1,022.00 $1,166.00 $946.00 $913.00 $1,014.00 $468.00 $1,216.00 $1,214.00 $1,280.00 $1,043.00 $1,349.00 $1,294.00 $1,473.00 $723.00 $1,112.00 $1,388.00 $1,343.00 $1,554.00 $1,403.00 $1,401.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$750.00 $821.00 $847.00 $2,180.00 $702.00 $893.00 $624.00 $615.00 $227.00 $603.00 $754.00 $1,047.00 $592.00 $910.00 $898.00 $1,089.00 $705.00 $800.00 $962.00 $973.00 $813.00 $629.00 $756.00 $987.00 $932.00 $896.00 $1,037.00 $1,125.00 $1,338.00 $1,428.00 $1,223.00 $1,175.00 $1,287.00 $976.00 $1,097.00 $948.00 $1,332.00 $1,469.00 $1,395.00 $1,118.00 $1,460.00 $1,267.00 $1,649.00 $1,137.00 $1,170.00 $1,513.00 $1,409.00 $1,710.00 $1,411.00 $1,651.00

$801.00 $876.00 $905.00 $2,327.00 $747.00 $951.00 $665.00 $655.00 $241.00 $644.00 $801.00 $1,118.00 $632.00 $970.00 $956.00 $1,162.00 $751.00 $852.00 $1,024.00 $1,037.00 $865.00 $671.00 $805.00 $1,051.00 $993.00 $954.00 $1,104.00 $1,201.00 $1,429.00 $1,521.00 $1,302.00 $1,239.00 $1,371.00 $1,040.00 $1,169.00 $1,010.00 $1,421.00 $1,567.00 $1,490.00 $1,190.00 $1,559.00 $1,336.00 $1,751.00 $1,214.00 $1,247.00 $1,612.00 $1,503.00 $1,825.00 $1,507.00 $1,762.00

$854.00 $934.00 $966.00 $2,508.00 $789.00 $1,010.00 $705.00 $691.00 $247.00 $687.00 $844.00 $1,199.00 $662.00 $1,029.00 $1,014.00 $1,242.00 $795.00 $906.00 $1,089.00 $1,102.00 $916.00 $710.00 $855.00 $1,116.00 $1,057.00 $1,013.00 $1,174.00 $1,286.00 $1,534.00 $1,614.00 $1,387.00 $1,312.00 $1,456.00 $1,106.00 $1,250.00 $1,075.00 $1,522.00 $1,677.00 $1,600.00 $1,268.00 $1,675.00 $1,415.00 $1,863.00 $1,299.00 $1,332.00 $1,723.00 $1,613.00 $1,959.00 $1,618.00 $1,896.00

$750.00 $821.00 $847.00 $2,180.00 $702.00 $893.00 $624.00 $615.00 $110.00 $603.00 $754.00 $1,047.00 $592.00 $910.00 $898.00 $1,089.00 $705.00 $800.00 $962.00 $973.00 $813.00 $629.00 $756.00 $987.00 $932.00 $896.00 $1,037.00 $1,125.00 $1,338.00 $1,428.00 $1,223.00 $1,175.00 $1,287.00 $976.00 $1,097.00 $948.00 $1,332.00 $1,469.00 $1,395.00 $1,118.00 $1,460.00 $1,267.00 $1,649.00 $1,137.00 $1,170.00 $1,513.00 $1,409.00 $1,710.00 $1,411.00 $1,651.00

$801.00 $876.00 $905.00 $2,327.00 $747.00 $951.00 $665.00 $655.00 $115.00 $644.00 $801.00 $1,118.00 $632.00 $970.00 $956.00 $1,162.00 $751.00 $852.00 $1,024.00 $1,037.00 $865.00 $671.00 $805.00 $1,051.00 $993.00 $954.00 $1,104.00 $1,201.00 $1,429.00 $1,521.00 $1,302.00 $1,239.00 $1,371.00 $1,040.00 $1,169.00 $1,010.00 $1,421.00 $1,567.00 $1,490.00 $1,190.00 $1,559.00 $1,336.00 $1,751.00 $1,214.00 $1,247.00 $1,612.00 $1,503.00 $1,825.00 $1,507.00 $1,762.00

$854.00 $934.00 $966.00 $2,508.00 $789.00 $1,010.00 $705.00 $691.00 $120.00 $687.00 $844.00 $1,199.00 $662.00 $1,029.00 $1,014.00 $1,242.00 $795.00 $906.00 $1,089.00 $1,102.00 $916.00 $710.00 $855.00 $1,116.00 $1,057.00 $1,013.00 $1,174.00 $1,286.00 $1,534.00 $1,614.00 $1,387.00 $1,312.00 $1,456.00 $1,106.00 $1,250.00 $1,075.00 $1,522.00 $1,677.00 $1,600.00 $1,268.00 $1,675.00 $1,415.00 $1,863.00 $1,299.00 $1,332.00 $1,723.00 $1,613.00 $1,959.00 $1,618.00 $1,896.00


Part B, 184



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$638.00 $631.00 $931.00 $1,147.00 $936.00 $970.00 $1,031.00 $959.00 $1,542.00 $952.00 $395.00 $805.00 $899.00 $955.00 $1,006.00 $1,170.00 $200.00 $517.00 $800.00 $644.00 $1,097.00 $1,293.00 $270.00 $516.00 $803.00 $276.00 $590.00 $804.00 $974.00 $312.00 $540.00 ----------------------------$148.00 $482.00 $716.00 $148.00 $458.00 $668.00 $185.00 $379.00 $560.00 $378.00 $731.00 $462.00 $404.00 $741.00 $471.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,066.00 $1,146.00 $1,113.00 $1,354.00 $1,169.00 $1,141.00 $1,207.00 $1,050.00 $1,707.00 $1,199.00 $1,505.00 $751.00 $890.00 $1,049.00 $1,080.00 $1,323.00 $387.00 $718.00 $972.00 $804.00 $1,141.00 $1,387.00 $370.00 $700.00 $902.00 $393.00 $743.00 $976.00 $1,313.00 $463.00 $782.00 $961.00 $1,066.00 $1,197.00 $1,524.00 $430.00 $678.00 $1,046.00 $433.00 $606.00 $824.00 $454.00 $697.00 $905.00 $585.00 $879.00 $767.00 $617.00 $909.00 $680.00

$1,138.00 $1,222.00 $1,185.00 $1,436.00 $1,244.00 $1,219.00 $1,289.00 $1,119.00 $1,816.00 $1,277.00 $1,601.00 $793.00 $940.00 $1,121.00 $1,154.00 $1,413.00 $413.00 $766.00 $1,037.00 $859.00 $1,217.00 $1,479.00 $395.00 $747.00 $963.00 $419.00 $792.00 $1,042.00 $1,401.00 $494.00 $833.00 $1,026.00 $1,137.00 $1,277.00 $1,624.00 $458.00 $724.00 $1,114.00 $461.00 $645.00 $880.00 $484.00 $742.00 $965.00 $623.00 $937.00 $819.00 $657.00 $969.00 $722.00

$1,217.00 $1,307.00 $1,262.00 $1,520.00 $1,322.00 $1,306.00 $1,382.00 $1,194.00 $1,939.00 $1,358.00 $1,708.00 $836.00 $992.00 $1,200.00 $1,236.00 $1,516.00 $431.00 $805.00 $1,105.00 $910.00 $1,298.00 $1,581.00 $412.00 $787.00 $1,024.00 $436.00 $835.00 $1,110.00 $1,497.00 $515.00 $879.00 $1,094.00 $1,211.00 $1,362.00 $1,733.00 $478.00 $762.00 $1,186.00 $483.00 $675.00 $938.00 $506.00 $784.00 $1,027.00 $657.00 $998.00 $870.00 $688.00 $1,031.00 $762.00

$1,066.00 $1,146.00 $1,113.00 $1,354.00 $1,169.00 $1,141.00 $1,207.00 $1,050.00 $1,707.00 $1,199.00 $1,505.00 $751.00 $890.00 $1,049.00 $1,080.00 $1,323.00 $357.00 $661.00 $972.00 $766.00 $1,141.00 $1,387.00 $337.00 $651.00 $902.00 $357.00 $676.00 $976.00 $1,313.00 $439.00 $738.00 $961.00 $1,066.00 $1,197.00 $1,524.00 $393.00 $621.00 $1,046.00 $400.00 $545.00 $824.00 $427.00 $697.00 $905.00 $585.00 $879.00 $767.00 $566.00 $909.00 $680.00

$1,138.00 $1,222.00 $1,185.00 $1,436.00 $1,244.00 $1,219.00 $1,289.00 $1,119.00 $1,816.00 $1,277.00 $1,601.00 $793.00 $940.00 $1,121.00 $1,154.00 $1,413.00 $380.00 $704.00 $1,037.00 $817.00 $1,217.00 $1,479.00 $360.00 $694.00 $963.00 $380.00 $720.00 $1,042.00 $1,401.00 $468.00 $786.00 $1,026.00 $1,137.00 $1,277.00 $1,624.00 $419.00 $663.00 $1,114.00 $426.00 $579.00 $880.00 $455.00 $742.00 $965.00 $623.00 $937.00 $819.00 $601.00 $969.00 $722.00

$1,217.00 $1,307.00 $1,262.00 $1,520.00 $1,322.00 $1,306.00 $1,382.00 $1,194.00 $1,939.00 $1,358.00 $1,708.00 $836.00 $992.00 $1,200.00 $1,236.00 $1,516.00 $398.00 $744.00 $1,105.00 $868.00 $1,298.00 $1,581.00 $376.00 $735.00 $1,024.00 $398.00 $763.00 $1,110.00 $1,497.00 $489.00 $832.00 $1,094.00 $1,211.00 $1,362.00 $1,733.00 $438.00 $701.00 $1,186.00 $447.00 $608.00 $938.00 $477.00 $784.00 $1,027.00 $657.00 $998.00 $870.00 $632.00 $1,031.00 $762.00


Part B, 185



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90

$887.00 $518.00 $520.00 $703.00 $1,078.00 $1,008.00 $2,276.00 $895.00 $991.00 $871.00 $900.00 $799.00 $849.00 $1,523.00 $771.00 $670.00 $768.00 $830.00 $645.00 $731.00 BR $59.00 $223.00 $484.00 $548.00 $655.00 $601.00 $741.00 $730.00 $367.00 $621.00 $343.00 $293.00 $440.00 $400.00 $382.00 $398.00 $481.00 $282.00 --------------$344.00 $544.00 $806.00 -------$833.00 $959.00 $342.00 $629.00 $668.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,068.00 $686.00 $923.00 $1,063.00 $1,234.00 $1,259.00 $887.00 $1,093.00 $1,358.00 $1,030.00 $956.00 $848.00 $999.00 $1,726.00 $1,009.00 $835.00 $887.00 $1,171.00 $861.00 $966.00 -------$367.00 $543.00 $624.00 $609.00 $710.00 $776.00 $1,235.00 $822.00 $446.00 $677.00 $778.00 $379.00 $450.00 $478.00 $560.00 $480.00 $478.00 $461.00 $605.00 $793.00 $711.00 $762.00 $1,088.00 $1,532.00 $864.00 $1,207.00 $405.00 $669.00 $793.00

$1,140.00 $733.00 $986.00 $1,132.00 $1,318.00 $1,340.00 $945.00 $1,164.00 $1,448.00 $1,099.00 $1,026.00 $905.00 $1,067.00 $1,838.00 $1,079.00 $892.00 $945.00 $1,252.00 $920.00 $1,036.00 -------$392.00 $581.00 $666.00 $649.00 $756.00 $827.00 $1,313.00 $875.00 $475.00 $723.00 $833.00 $404.00 $479.00 $509.00 $597.00 $512.00 $510.00 $491.00 $645.00 $845.00 $759.00 $812.00 $1,159.00 $1,632.00 $921.00 $1,286.00 $431.00 $714.00 $844.00

$1,221.00 $777.00 $1,054.00 $1,205.00 $1,413.00 $1,426.00 $1,000.00 $1,233.00 $1,527.00 $1,173.00 $1,117.00 $968.00 $1,143.00 $1,968.00 $1,153.00 $955.00 $1,010.00 $1,328.00 $985.00 $1,113.00 -------$401.00 $598.00 $704.00 $687.00 $801.00 $878.00 $1,389.00 $931.00 $500.00 $767.00 $858.00 $425.00 $504.00 $537.00 $631.00 $543.00 $538.00 $518.00 $685.00 $897.00 $790.00 $862.00 $1,234.00 $1,743.00 $978.00 $1,366.00 $464.00 $760.00 $894.00

$1,068.00 $686.00 $923.00 $1,063.00 $1,234.00 $1,259.00 $887.00 $1,093.00 $1,358.00 $1,030.00 $956.00 $848.00 $999.00 $1,726.00 $1,009.00 $835.00 $887.00 $1,171.00 $861.00 $966.00 -------$196.00 $266.00 $624.00 $609.00 $710.00 $776.00 $1,235.00 $822.00 $446.00 $677.00 $443.00 $379.00 $450.00 $478.00 $560.00 $480.00 $478.00 $461.00 $605.00 $793.00 $479.00 $762.00 $1,088.00 $1,532.00 $864.00 $1,207.00 $405.00 $669.00 $793.00

$1,140.00 $733.00 $986.00 $1,132.00 $1,318.00 $1,340.00 $945.00 $1,164.00 $1,448.00 $1,099.00 $1,026.00 $905.00 $1,067.00 $1,838.00 $1,079.00 $892.00 $945.00 $1,252.00 $920.00 $1,036.00 -------$208.00 $283.00 $666.00 $649.00 $756.00 $827.00 $1,313.00 $875.00 $475.00 $723.00 $473.00 $404.00 $479.00 $509.00 $597.00 $512.00 $510.00 $491.00 $645.00 $845.00 $511.00 $812.00 $1,159.00 $1,632.00 $921.00 $1,286.00 $431.00 $714.00 $844.00

$1,221.00 $777.00 $1,054.00 $1,205.00 $1,413.00 $1,426.00 $1,000.00 $1,233.00 $1,527.00 $1,173.00 $1,117.00 $968.00 $1,143.00 $1,968.00 $1,153.00 $955.00 $1,010.00 $1,328.00 $985.00 $1,113.00 -------$217.00 $299.00 $704.00 $687.00 $801.00 $878.00 $1,389.00 $931.00 $500.00 $767.00 $496.00 $425.00 $504.00 $537.00 $631.00 $543.00 $538.00 $518.00 $685.00 $897.00 $540.00 $862.00 $1,234.00 $1,743.00 $978.00 $1,366.00 $464.00 $760.00 $894.00


Part B, 186



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$678.00 $660.00 $319.00 $452.00 $444.00 $511.00 $598.00 $788.00 $543.00 $731.00 $624.00 $612.00 $444.00 $814.00 $758.00 $624.00 $414.00 $266.00 -------$715.00 $855.00 $886.00 $932.00 $979.00 $832.00 $945.00 $904.00 $889.00 $1,123.00 $371.00 $737.00 $846.00 $1,093.00 $444.00 $741.00 $733.00 $790.00 $430.00 $371.00 $656.00 $491.00 $458.00 $548.00 $455.00 $738.00 $353.00 $364.00 $346.00 $592.00 $586.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$727.00 $739.00 $803.00 $581.00 $636.00 $779.00 $649.00 $877.00 $636.00 $818.00 $720.00 $712.00 $636.00 $1,565.00 $1,162.00 $901.00 $498.00 $472.00 $140.00 $996.00 $1,156.00 $1,254.00 $1,243.00 $1,384.00 $1,064.00 $1,244.00 $1,194.00 $1,193.00 $1,374.00 $791.00 $957.00 $1,089.00 $1,031.00 $805.00 $994.00 $723.00 $1,063.00 $697.00 $744.00 $912.00 $875.00 $864.00 $1,359.00 $803.00 $1,000.00 $573.00 $563.00 $553.00 $861.00 $846.00

$774.00 $787.00 $859.00 $619.00 $676.00 $827.00 $691.00 $937.00 $678.00 $874.00 $766.00 $758.00 $678.00 $1,663.00 $1,235.00 $956.00 $531.00 $505.00 $150.00 $1,064.00 $1,237.00 $1,337.00 $1,327.00 $1,478.00 $1,135.00 $1,328.00 $1,276.00 $1,276.00 $1,468.00 $845.00 $1,022.00 $1,161.00 $1,096.00 $860.00 $1,060.00 $770.00 $1,136.00 $744.00 $794.00 $974.00 $934.00 $922.00 $1,449.00 $857.00 $1,064.00 $612.00 $601.00 $590.00 $918.00 $904.00

$820.00 $836.00 $887.00 $653.00 $714.00 $869.00 $732.00 $1,002.00 $717.00 $934.00 $812.00 $803.00 $718.00 $1,766.00 $1,310.00 $1,007.00 $561.00 $526.00 $156.00 $1,110.00 $1,302.00 $1,407.00 $1,412.00 $1,576.00 $1,188.00 $1,398.00 $1,343.00 $1,353.00 $1,551.00 $882.00 $1,071.00 $1,223.00 $1,158.00 $894.00 $1,111.00 $816.00 $1,193.00 $775.00 $829.00 $1,024.00 $978.00 $960.00 $1,521.00 $891.00 $1,125.00 $640.00 $627.00 $617.00 $959.00 $949.00

$727.00 $739.00 $478.00 $581.00 $636.00 $779.00 $649.00 $877.00 $636.00 $818.00 $720.00 $712.00 $636.00 $1,565.00 $1,162.00 $901.00 $498.00 $472.00 $108.00 $996.00 $1,156.00 $1,254.00 $1,243.00 $1,384.00 $1,064.00 $1,244.00 $1,194.00 $1,193.00 $1,374.00 $791.00 $957.00 $1,089.00 $1,031.00 $805.00 $994.00 $723.00 $1,063.00 $697.00 $744.00 $912.00 $875.00 $864.00 $1,359.00 $803.00 $1,000.00 $573.00 $563.00 $553.00 $861.00 $846.00

$774.00 $787.00 $510.00 $619.00 $676.00 $827.00 $691.00 $937.00 $678.00 $874.00 $766.00 $758.00 $678.00 $1,663.00 $1,235.00 $956.00 $531.00 $505.00 $115.00 $1,064.00 $1,237.00 $1,337.00 $1,327.00 $1,478.00 $1,135.00 $1,328.00 $1,276.00 $1,276.00 $1,468.00 $845.00 $1,022.00 $1,161.00 $1,096.00 $860.00 $1,060.00 $770.00 $1,136.00 $744.00 $794.00 $974.00 $934.00 $922.00 $1,449.00 $857.00 $1,064.00 $612.00 $601.00 $590.00 $918.00 $904.00

$820.00 $836.00 $536.00 $653.00 $714.00 $869.00 $732.00 $1,002.00 $717.00 $934.00 $812.00 $803.00 $718.00 $1,766.00 $1,310.00 $1,007.00 $561.00 $526.00 $122.00 $1,110.00 $1,302.00 $1,407.00 $1,412.00 $1,576.00 $1,188.00 $1,398.00 $1,343.00 $1,353.00 $1,551.00 $882.00 $1,071.00 $1,223.00 $1,158.00 $894.00 $1,111.00 $816.00 $1,193.00 $775.00 $829.00 $1,024.00 $978.00 $960.00 $1,521.00 $891.00 $1,125.00 $640.00 $627.00 $617.00 $959.00 $949.00


Part B, 187



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$543.00 $553.00 $608.00 $653.00 $808.00 $986.00 $891.00 $738.00 $496.00 $971.00 $946.00 $949.00 $946.00 $1,317.00 $934.00 $557.00 $715.00 $334.00 $564.00 $630.00 $890.00 $877.00 $583.00 $531.00 $708.00 $877.00 $546.00 $770.00 $726.00 $926.00 $716.00 $722.00 $918.00 $665.00 $1,861.00 $3,901.00 $3,868.00 $4,551.00 $1,567.00 $4,005.00 $576.00 $1,067.00 $1,017.00 $730.00 $622.00 $1,003.00 $1,585.00 $792.00 $1,609.00 $431.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$808.00 $813.00 $871.00 $857.00 $1,051.00 $1,188.00 $1,135.00 $1,283.00 $1,110.00 $1,232.00 $1,116.00 $1,214.00 $1,235.00 $1,642.00 $1,182.00 $875.00 $978.00 $905.00 $831.00 $984.00 $1,170.00 $1,163.00 $908.00 $910.00 $774.00 $901.00 $605.00 $998.00 $924.00 $1,133.00 $953.00 $970.00 $1,404.00 $1,072.00 $2,219.00 $4,138.00 $4,797.00 $4,816.00 $1,924.00 $4,982.00 $786.00 $1,321.00 $1,932.00 $953.00 $958.00 $1,275.00 $2,103.00 $1,325.00 $1,958.00 $606.00

$861.00 $867.00 $929.00 $912.00 $1,120.00 $1,267.00 $1,211.00 $1,364.00 $1,183.00 $1,310.00 $1,190.00 $1,293.00 $1,320.00 $1,754.00 $1,263.00 $933.00 $1,041.00 $968.00 $885.00 $1,049.00 $1,250.00 $1,237.00 $970.00 $971.00 $825.00 $960.00 $643.00 $1,064.00 $985.00 $1,207.00 $1,016.00 $1,034.00 $1,497.00 $1,142.00 $2,355.00 $4,364.00 $5,122.00 $5,078.00 $2,049.00 $5,321.00 $838.00 $1,406.00 $2,065.00 $1,016.00 $1,021.00 $1,363.00 $2,235.00 $1,402.00 $2,092.00 $647.00

$896.00 $906.00 $972.00 $951.00 $1,168.00 $1,330.00 $1,268.00 $1,426.00 $1,243.00 $1,375.00 $1,253.00 $1,361.00 $1,400.00 $1,869.00 $1,338.00 $978.00 $1,088.00 $1,018.00 $923.00 $1,099.00 $1,321.00 $1,296.00 $1,011.00 $1,012.00 $874.00 $1,018.00 $678.00 $1,109.00 $1,032.00 $1,271.00 $1,065.00 $1,084.00 $1,576.00 $1,200.00 $2,492.00 $4,625.00 $5,514.00 $5,386.00 $2,171.00 $5,725.00 $875.00 $1,482.00 $2,201.00 $1,066.00 $1,071.00 $1,437.00 $2,367.00 $1,488.00 $2,247.00 $671.00

$808.00 $813.00 $871.00 $857.00 $1,051.00 $1,188.00 $1,135.00 $1,283.00 $1,110.00 $1,232.00 $1,116.00 $1,214.00 $1,235.00 $1,642.00 $1,182.00 $875.00 $978.00 $905.00 $831.00 $984.00 $1,170.00 $1,163.00 $908.00 $910.00 $774.00 $901.00 $605.00 $998.00 $924.00 $1,133.00 $953.00 $970.00 $1,404.00 $1,072.00 $2,219.00 $4,138.00 $4,797.00 $4,816.00 $1,924.00 $4,982.00 $786.00 $1,321.00 $1,932.00 $953.00 $958.00 $1,275.00 $2,103.00 $1,325.00 $1,958.00 $606.00

$861.00 $867.00 $929.00 $912.00 $1,120.00 $1,267.00 $1,211.00 $1,364.00 $1,183.00 $1,310.00 $1,190.00 $1,293.00 $1,320.00 $1,754.00 $1,263.00 $933.00 $1,041.00 $968.00 $885.00 $1,049.00 $1,250.00 $1,237.00 $970.00 $971.00 $825.00 $960.00 $643.00 $1,064.00 $985.00 $1,207.00 $1,016.00 $1,034.00 $1,497.00 $1,142.00 $2,355.00 $4,364.00 $5,122.00 $5,078.00 $2,049.00 $5,321.00 $838.00 $1,406.00 $2,065.00 $1,016.00 $1,021.00 $1,363.00 $2,235.00 $1,402.00 $2,092.00 $647.00

$896.00 $906.00 $972.00 $951.00 $1,168.00 $1,330.00 $1,268.00 $1,426.00 $1,243.00 $1,375.00 $1,253.00 $1,361.00 $1,400.00 $1,869.00 $1,338.00 $978.00 $1,088.00 $1,018.00 $923.00 $1,099.00 $1,321.00 $1,296.00 $1,011.00 $1,012.00 $874.00 $1,018.00 $678.00 $1,109.00 $1,032.00 $1,271.00 $1,065.00 $1,084.00 $1,576.00 $1,200.00 $2,492.00 $4,625.00 $5,514.00 $5,386.00 $2,171.00 $5,725.00 $875.00 $1,482.00 $2,201.00 $1,066.00 $1,071.00 $1,437.00 $2,367.00 $1,488.00 $2,247.00 $671.00


Part B, 188



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 90 YYY

$587.00 $809.00 $133.00 $296.00 $334.00 $497.00 $521.00 $71.00 $371.00 $533.00 $693.00 $148.00 $501.00 $527.00 $592.00 $710.00 $88.00 $296.00 $469.00 $526.00 $96.00 $187.00 $187.00 $532.00 $148.00 $148.00 $548.00 $96.00 $133.00 $366.00 $398.00 $79.00 $275.00 $401.00 $408.00 $854.00 $756.00 $901.00 $800.00 $875.00 $704.00 $829.00 $542.00 $151.00 $747.00 $317.00 $747.00 $444.00 $608.00 BR

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$839.00 $1,068.00 $415.00 $456.00 $654.00 $685.00 $832.00 $523.00 $603.00 $685.00 $917.00 $482.00 $646.00 $718.00 $831.00 $907.00 $458.00 $594.00 $633.00 $824.00 $279.00 $478.00 $673.00 $861.00 $325.00 $524.00 $1,074.00 $260.00 $444.00 $597.00 $720.00 $390.00 $543.00 $635.00 $789.00 $1,116.00 $1,023.00 $1,111.00 $1,048.00 $1,145.00 $973.00 $1,123.00 $789.00 $153.00 $1,023.00 $342.00 $1,020.00 $919.00 $908.00 --------

$895.00 $1,134.00 $443.00 $486.00 $697.00 $730.00 $887.00 $556.00 $643.00 $731.00 $980.00 $512.00 $690.00 $766.00 $886.00 $969.00 $487.00 $633.00 $675.00 $878.00 $297.00 $510.00 $718.00 $918.00 $347.00 $559.00 $1,144.00 $276.00 $473.00 $637.00 $768.00 $413.00 $579.00 $677.00 $841.00 $1,192.00 $1,091.00 $1,185.00 $1,121.00 $1,219.00 $1,037.00 $1,197.00 $843.00 $162.00 $1,091.00 $365.00 $1,088.00 $981.00 $968.00 --------

$934.00 $1,191.00 $461.00 $508.00 $738.00 $772.00 $940.00 $582.00 $679.00 $772.00 $1,045.00 $537.00 $729.00 $809.00 $939.00 $1,036.00 $510.00 $665.00 $714.00 $929.00 $309.00 $534.00 $759.00 $974.00 $362.00 $587.00 $1,217.00 $288.00 $493.00 $670.00 $811.00 $432.00 $606.00 $714.00 $891.00 $1,259.00 $1,146.00 $1,248.00 $1,185.00 $1,279.00 $1,088.00 $1,259.00 $879.00 $175.00 $1,145.00 $396.00 $1,148.00 $1,028.00 $1,016.00 --------

$839.00 $1,068.00 $392.00 $417.00 $654.00 $685.00 $832.00 $479.00 $557.00 $685.00 $917.00 $440.00 $596.00 $718.00 $831.00 $907.00 $432.00 $547.00 $633.00 $824.00 $260.00 $434.00 $673.00 $861.00 $306.00 $479.00 $1,074.00 $260.00 $389.00 $597.00 $720.00 $362.00 $494.00 $635.00 $789.00 $1,116.00 $1,023.00 $1,111.00 $1,048.00 $1,145.00 $973.00 $1,123.00 $789.00 $153.00 $1,023.00 $342.00 $1,020.00 $919.00 $908.00 --------

$895.00 $1,134.00 $418.00 $445.00 $697.00 $730.00 $887.00 $509.00 $594.00 $731.00 $980.00 $467.00 $637.00 $766.00 $886.00 $969.00 $458.00 $583.00 $675.00 $878.00 $277.00 $462.00 $718.00 $918.00 $327.00 $510.00 $1,144.00 $277.00 $413.00 $637.00 $768.00 $384.00 $526.00 $677.00 $841.00 $1,192.00 $1,091.00 $1,185.00 $1,121.00 $1,219.00 $1,037.00 $1,197.00 $843.00 $162.00 $1,091.00 $365.00 $1,088.00 $981.00 $968.00 --------

$934.00 $1,191.00 $436.00 $467.00 $738.00 $772.00 $940.00 $535.00 $629.00 $772.00 $1,045.00 $491.00 $676.00 $809.00 $939.00 $1,036.00 $481.00 $615.00 $714.00 $929.00 $289.00 $486.00 $759.00 $974.00 $342.00 $538.00 $1,217.00 $288.00 $434.00 $670.00 $811.00 $402.00 $553.00 $714.00 $891.00 $1,259.00 $1,146.00 $1,248.00 $1,185.00 $1,279.00 $1,088.00 $1,259.00 $879.00 $175.00 $1,145.00 $396.00 $1,148.00 $1,028.00 $1,016.00 --------


Part B, 189



90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 0 0 90 90 90 90 90

$592.00 $466.00 $1,146.00 $421.00 $550.00 $698.00 $738.00 $788.00 $896.00 -------$1,148.00 $1,173.00 $1,413.00 $1,176.00 $196.00 $699.00 --------------$535.00 $588.00 $1,162.00 $449.00 $624.00 $843.00 --------------$491.00 $499.00 $583.00 $931.00 $1,234.00 $1,040.00 $1,112.00 $1,485.00 $1,859.00 $1,976.00 $1,164.00 $568.00 $57.00 $555.00 $981.00 $1,482.00 $62.00 $121.00 $491.00 $795.00 $799.00 $987.00 $946.00 $1,174.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$908.00 $1,004.00 $1,398.00 $603.00 $780.00 $866.00 $1,055.00 $1,071.00 $1,336.00 $1,319.00 $1,371.00 $1,424.00 $1,683.00 $1,477.00 $486.00 $1,008.00 $695.00 $1,104.00 $672.00 $900.00 $1,997.00 $554.00 $838.00 $997.00 $1,490.00 $2,696.00 $672.00 $663.00 $742.00 $1,182.00 $1,498.00 $1,235.00 $1,337.00 $3,096.00 $3,740.00 $4,208.00 $3,048.00 $751.00 $408.00 $915.00 $1,213.00 $2,352.00 $262.00 $337.00 $226.00 $981.00 $973.00 $1,193.00 $1,268.00 $1,416.00

$970.00 $1,072.00 $1,490.00 $640.00 $832.00 $925.00 $1,125.00 $1,142.00 $1,424.00 $1,408.00 $1,463.00 $1,519.00 $1,792.00 $1,575.00 $518.00 $1,073.00 $745.00 $1,181.00 $719.00 $963.00 $2,133.00 $590.00 $895.00 $1,063.00 $1,591.00 $2,879.00 $718.00 $708.00 $791.00 $1,261.00 $1,596.00 $1,317.00 $1,427.00 $3,304.00 $3,990.00 $4,492.00 $3,252.00 $804.00 $437.00 $976.00 $1,294.00 $2,509.00 $279.00 $359.00 $239.00 $1,047.00 $1,035.00 $1,271.00 $1,354.00 $1,512.00

$1,036.00 $1,127.00 $1,592.00 $677.00 $887.00 $987.00 $1,202.00 $1,219.00 $1,522.00 $1,511.00 $1,570.00 $1,630.00 $1,919.00 $1,687.00 $537.00 $1,148.00 $808.00 $1,275.00 $762.00 $1,040.00 $2,312.00 $623.00 $955.00 $1,135.00 $1,713.00 $3,120.00 $765.00 $755.00 $842.00 $1,347.00 $1,708.00 $1,407.00 $1,525.00 $3,565.00 $4,309.00 $4,859.00 $3,508.00 $864.00 $453.00 $1,045.00 $1,386.00 $2,698.00 $285.00 $367.00 $245.00 $1,119.00 $1,102.00 $1,357.00 $1,452.00 $1,621.00

$908.00 $758.00 $1,398.00 $603.00 $780.00 $866.00 $1,055.00 $1,071.00 $1,336.00 $1,319.00 $1,371.00 $1,424.00 $1,683.00 $1,477.00 $291.00 $1,008.00 $695.00 $1,104.00 $531.00 $900.00 $1,997.00 $554.00 $838.00 $997.00 $1,490.00 $2,696.00 $672.00 $663.00 $742.00 $1,182.00 $1,498.00 $1,235.00 $1,337.00 $3,096.00 $3,740.00 $4,208.00 $3,048.00 $751.00 $240.00 $915.00 $1,213.00 $2,352.00 $102.00 $121.00 $122.00 $981.00 $973.00 $1,193.00 $1,268.00 $1,416.00

$970.00 $809.00 $1,490.00 $640.00 $832.00 $925.00 $1,125.00 $1,142.00 $1,424.00 $1,408.00 $1,463.00 $1,519.00 $1,792.00 $1,575.00 $309.00 $1,073.00 $745.00 $1,181.00 $568.00 $963.00 $2,133.00 $590.00 $895.00 $1,063.00 $1,591.00 $2,879.00 $718.00 $708.00 $791.00 $1,261.00 $1,596.00 $1,317.00 $1,427.00 $3,304.00 $3,990.00 $4,492.00 $3,252.00 $804.00 $256.00 $976.00 $1,294.00 $2,509.00 $107.00 $127.00 $128.00 $1,047.00 $1,035.00 $1,271.00 $1,354.00 $1,512.00

$1,036.00 $863.00 $1,592.00 $677.00 $887.00 $987.00 $1,202.00 $1,219.00 $1,522.00 $1,511.00 $1,570.00 $1,630.00 $1,919.00 $1,687.00 $327.00 $1,148.00 $808.00 $1,275.00 $610.00 $1,040.00 $2,312.00 $623.00 $955.00 $1,135.00 $1,713.00 $3,120.00 $765.00 $755.00 $842.00 $1,347.00 $1,708.00 $1,407.00 $1,525.00 $3,565.00 $4,309.00 $4,859.00 $3,508.00 $864.00 $272.00 $1,045.00 $1,386.00 $2,698.00 $113.00 $135.00 $133.00 $1,119.00 $1,102.00 $1,357.00 $1,452.00 $1,621.00


Part B, 190



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0

$1,099.00 $1,603.00 $1,406.00 $1,371.00 $1,853.00 $2,128.00 $2,576.00 $2,190.00 $2,025.00 $1,092.00 $1,432.00 $1,744.00 $1,732.00 $2,017.00 $1,588.00 $1,443.00 $1,572.00 $1,453.00 $491.00 $1,024.00 $1,257.00 $1,020.00 $1,107.00 $1,206.00 $676.00 $1,280.00 $425.00 $740.00 $180.00 $776.00 $954.00 $1,085.00 $1,285.00 $1,570.00 $444.00 $973.00 $1,350.00 $1,967.00 $2,195.00 $491.00 $916.00 $1,128.00 $1,421.00 $504.00 $1,043.00 $1,426.00 $1,691.00 $459.00 $980.00 $535.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,317.00 $1,913.00 $1,613.00 $1,665.00 $1,996.00 $2,467.00 $2,829.00 $2,171.00 $2,256.00 $1,308.00 $1,893.00 $2,168.00 $2,340.00 $2,534.00 $2,108.00 $1,783.00 $2,018.00 $1,729.00 $977.00 $1,317.00 $1,637.00 $1,345.00 $1,432.00 $1,407.00 $885.00 $1,453.00 $683.00 $1,032.00 $258.00 $772.00 $910.00 $1,350.00 $1,266.00 $1,753.00 $770.00 $1,430.00 $1,551.00 $2,446.00 $2,791.00 $685.00 $1,105.00 $1,334.00 $1,758.00 $666.00 $1,402.00 $1,810.00 $1,809.00 $558.00 $1,089.00 $269.00

$1,407.00 $2,043.00 $1,720.00 $1,776.00 $2,128.00 $2,630.00 $3,016.00 $2,314.00 $2,405.00 $1,395.00 $2,022.00 $2,315.00 $2,496.00 $2,706.00 $2,260.00 $1,901.00 $2,151.00 $1,844.00 $1,043.00 $1,404.00 $1,748.00 $1,436.00 $1,529.00 $1,484.00 $934.00 $1,550.00 $729.00 $1,099.00 $275.00 $823.00 $960.00 $1,424.00 $1,335.00 $1,848.00 $822.00 $1,526.00 $1,654.00 $2,609.00 $2,977.00 $731.00 $1,176.00 $1,424.00 $1,875.00 $711.00 $1,496.00 $1,931.00 $1,930.00 $595.00 $1,161.00 $284.00

$1,510.00 $2,199.00 $1,846.00 $1,908.00 $2,289.00 $2,828.00 $3,249.00 $2,490.00 $2,588.00 $1,493.00 $2,177.00 $2,494.00 $2,687.00 $2,918.00 $2,454.00 $2,041.00 $2,308.00 $1,982.00 $1,120.00 $1,504.00 $1,879.00 $1,541.00 $1,643.00 $1,571.00 $987.00 $1,662.00 $776.00 $1,174.00 $288.00 $878.00 $1,017.00 $1,508.00 $1,414.00 $1,961.00 $876.00 $1,637.00 $1,776.00 $2,810.00 $3,209.00 $776.00 $1,263.00 $1,529.00 $2,014.00 $755.00 $1,605.00 $2,075.00 $2,073.00 $633.00 $1,246.00 $307.00

$1,317.00 $1,913.00 $1,613.00 $1,665.00 $1,996.00 $2,467.00 $2,829.00 $2,171.00 $2,256.00 $1,308.00 $1,893.00 $2,168.00 $2,340.00 $2,534.00 $2,108.00 $1,783.00 $2,018.00 $1,729.00 $977.00 $1,317.00 $1,637.00 $1,345.00 $1,432.00 $1,407.00 $885.00 $1,453.00 $691.00 $1,032.00 $268.00 $772.00 $910.00 $1,350.00 $1,266.00 $1,753.00 $764.00 $1,430.00 $1,551.00 $2,446.00 $2,791.00 $681.00 $1,105.00 $1,334.00 $1,758.00 $666.00 $1,402.00 $1,810.00 $1,809.00 $560.00 $1,089.00 $269.00

$1,407.00 $2,043.00 $1,720.00 $1,776.00 $2,128.00 $2,630.00 $3,016.00 $2,314.00 $2,405.00 $1,395.00 $2,022.00 $2,315.00 $2,496.00 $2,706.00 $2,260.00 $1,901.00 $2,151.00 $1,844.00 $1,043.00 $1,404.00 $1,748.00 $1,436.00 $1,529.00 $1,484.00 $934.00 $1,550.00 $738.00 $1,099.00 $286.00 $823.00 $960.00 $1,424.00 $1,335.00 $1,848.00 $815.00 $1,526.00 $1,654.00 $2,609.00 $2,977.00 $727.00 $1,176.00 $1,424.00 $1,875.00 $711.00 $1,496.00 $1,931.00 $1,930.00 $598.00 $1,161.00 $284.00

$1,510.00 $2,199.00 $1,846.00 $1,908.00 $2,289.00 $2,828.00 $3,249.00 $2,490.00 $2,588.00 $1,493.00 $2,177.00 $2,494.00 $2,687.00 $2,918.00 $2,454.00 $2,041.00 $2,308.00 $1,982.00 $1,120.00 $1,504.00 $1,879.00 $1,541.00 $1,643.00 $1,571.00 $987.00 $1,662.00 $785.00 $1,174.00 $300.00 $878.00 $1,017.00 $1,508.00 $1,414.00 $1,961.00 $869.00 $1,637.00 $1,776.00 $2,810.00 $3,209.00 $772.00 $1,263.00 $1,529.00 $2,014.00 $755.00 $1,605.00 $2,075.00 $2,073.00 $636.00 $1,246.00 $307.00


Part B, 191



90 90 90 10 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ

$520.00 $1,162.00 $1,478.00 $338.00 $455.00 $1,355.00 $1,803.00 $442.00 $614.00 ---------------------$220.00 -------$1,179.00 $990.00 $1,435.00 $1,503.00 $2,073.00 $1,594.00 BR $193.00 $520.00 $555.00 $377.00 $503.00 $877.00 $211.00 $433.00 --------------$400.00 $503.00 $1,249.00 $492.00 $585.00 $786.00 $719.00 $840.00 $959.00 --------------$405.00 $565.00 $394.00 $786.00 $763.00 $882.00 $950.00 $394.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,111.00 $1,378.00 $1,863.00 $431.00 $534.00 $1,631.00 $2,290.00 $574.00 $847.00 $630.00 $774.00 $1,827.00 $263.00 $1,027.00 $2,037.00 $1,204.00 $2,296.00 $2,402.00 $2,375.00 $1,861.00 -------$962.00 $929.00 $697.00 $511.00 $669.00 $1,067.00 $384.00 $581.00 $794.00 $755.00 $655.00 $912.00 $1,529.00 $606.00 $689.00 $932.00 $852.00 $995.00 $1,113.00 $616.00 $1,111.00 $537.00 $697.00 $769.00 $947.00 $875.00 $1,074.00 $1,188.00 $413.00

$1,184.00 $1,471.00 $1,986.00 $457.00 $571.00 $1,742.00 $2,445.00 $609.00 $905.00 $672.00 $826.00 $1,948.00 $281.00 $1,106.00 $2,196.00 $1,282.00 $2,442.00 $2,555.00 $2,535.00 $1,987.00 -------$1,030.00 $991.00 $744.00 $540.00 $713.00 $1,138.00 $410.00 $622.00 $847.00 $808.00 $701.00 $975.00 $1,634.00 $648.00 $735.00 $995.00 $911.00 $1,062.00 $1,188.00 $660.00 $1,189.00 $574.00 $744.00 $821.00 $1,011.00 $934.00 $1,145.00 $1,268.00 $440.00

$1,270.00 $1,578.00 $2,134.00 $484.00 $614.00 $1,873.00 $2,634.00 $642.00 $967.00 $714.00 $880.00 $2,096.00 $298.00 $1,204.00 $2,413.00 $1,368.00 $2,624.00 $2,737.00 $2,735.00 $2,146.00 -------$1,087.00 $1,059.00 $791.00 $566.00 $758.00 $1,217.00 $426.00 $667.00 $903.00 $865.00 $736.00 $1,050.00 $1,766.00 $690.00 $783.00 $1,062.00 $972.00 $1,134.00 $1,270.00 $713.00 $1,284.00 $610.00 $792.00 $875.00 $1,078.00 $997.00 $1,225.00 $1,358.00 $476.00

$1,111.00 $1,378.00 $1,863.00 $344.00 $534.00 $1,631.00 $2,290.00 $574.00 $847.00 $630.00 $774.00 $1,827.00 $263.00 $1,027.00 $2,037.00 $1,204.00 $2,296.00 $2,402.00 $2,375.00 $1,861.00 -------$732.00 $929.00 $697.00 $511.00 $669.00 $1,067.00 $258.00 $581.00 $794.00 $755.00 $458.00 $912.00 $1,529.00 $606.00 $689.00 $932.00 $852.00 $995.00 $1,113.00 $616.00 $1,111.00 $537.00 $697.00 $769.00 $947.00 $875.00 $1,074.00 $1,188.00 $413.00

$1,184.00 $1,471.00 $1,986.00 $364.00 $571.00 $1,742.00 $2,445.00 $609.00 $905.00 $672.00 $826.00 $1,948.00 $281.00 $1,106.00 $2,196.00 $1,282.00 $2,442.00 $2,555.00 $2,535.00 $1,987.00 -------$783.00 $991.00 $744.00 $540.00 $713.00 $1,138.00 $275.00 $622.00 $847.00 $808.00 $490.00 $975.00 $1,634.00 $648.00 $735.00 $995.00 $911.00 $1,062.00 $1,188.00 $660.00 $1,189.00 $574.00 $744.00 $821.00 $1,011.00 $934.00 $1,145.00 $1,268.00 $440.00

$1,270.00 $1,578.00 $2,134.00 $390.00 $614.00 $1,873.00 $2,634.00 $642.00 $967.00 $714.00 $880.00 $2,096.00 $298.00 $1,204.00 $2,413.00 $1,368.00 $2,624.00 $2,737.00 $2,735.00 $2,146.00 -------$839.00 $1,059.00 $791.00 $566.00 $758.00 $1,217.00 $291.00 $667.00 $903.00 $865.00 $524.00 $1,050.00 $1,766.00 $690.00 $783.00 $1,062.00 $972.00 $1,134.00 $1,270.00 $713.00 $1,284.00 $610.00 $792.00 $875.00 $1,078.00 $997.00 $1,225.00 $1,358.00 $476.00


Part B, 192



90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$977.00 -------$1,421.00 $75.00 $371.00 $698.00 $1,118.00 $753.00 $1,064.00 $506.00 $647.00 $834.00 $608.00 $748.00 $1,093.00 $742.00 $989.00 $832.00 $792.00 $842.00 $918.00 $1,212.00 ---------------------$1,596.00 $927.00 $930.00 $927.00 $639.00 $1,118.00 $1,266.00 $2,333.00 $884.00 $501.00 $819.00 $1,065.00 $1,064.00 $1,006.00 $1,117.00 $1,037.00 $1,618.00 $1,764.00 $1,960.00 $1,060.00 $1,311.00 $1,524.00 $1,157.00 $1,209.00 $1,253.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,240.00 $2,313.00 $3,057.00 $216.00 $861.00 $861.00 $1,160.00 $831.00 $1,207.00 $649.00 $839.00 $1,033.00 $735.00 $920.00 $1,285.00 $897.00 $1,322.00 $1,013.00 $932.00 $982.00 $1,135.00 $1,395.00 $2,434.00 $2,013.00 $1,434.00 $1,210.00 $1,086.00 $1,082.00 $1,093.00 $649.00 $1,038.00 $1,629.00 $1,820.00 $1,078.00 $1,175.00 $964.00 $1,228.00 $1,168.00 $1,204.00 $1,271.00 $1,179.00 $1,834.00 $1,705.00 $1,996.00 $1,131.00 $1,480.00 $1,913.00 $1,378.00 $1,386.00 $1,815.00

$1,323.00 $2,471.00 $3,261.00 $230.00 $921.00 $919.00 $1,237.00 $887.00 $1,288.00 $693.00 $897.00 $1,101.00 $784.00 $975.00 $1,373.00 $959.00 $1,412.00 $1,082.00 $995.00 $1,047.00 $1,211.00 $1,487.00 $2,598.00 $2,149.00 $1,531.00 $1,290.00 $1,158.00 $1,154.00 $1,168.00 $693.00 $1,106.00 $1,738.00 $1,941.00 $1,150.00 $1,253.00 $1,029.00 $1,310.00 $1,247.00 $1,285.00 $1,356.00 $1,258.00 $1,956.00 $1,817.00 $2,128.00 $1,201.00 $1,578.00 $2,043.00 $1,471.00 $1,476.00 $1,935.00

$1,413.00 $2,675.00 $3,517.00 $235.00 $962.00 $978.00 $1,321.00 $942.00 $1,374.00 $737.00 $958.00 $1,173.00 $834.00 $1,026.00 $1,472.00 $1,025.00 $1,514.00 $1,158.00 $1,062.00 $1,117.00 $1,296.00 $1,593.00 $2,796.00 $2,309.00 $1,643.00 $1,380.00 $1,239.00 $1,233.00 $1,251.00 $738.00 $1,181.00 $1,861.00 $2,075.00 $1,228.00 $1,337.00 $1,102.00 $1,402.00 $1,338.00 $1,377.00 $1,452.00 $1,347.00 $2,101.00 $1,953.00 $2,288.00 $1,278.00 $1,690.00 $2,199.00 $1,578.00 $1,580.00 $2,078.00

$1,240.00 $2,313.00 $3,057.00 $74.00 $586.00 $861.00 $1,160.00 $831.00 $1,207.00 $649.00 $839.00 $1,033.00 $735.00 $920.00 $1,285.00 $897.00 $1,322.00 $1,013.00 $932.00 $982.00 $1,135.00 $1,395.00 $2,434.00 $2,013.00 $1,434.00 $1,210.00 $1,086.00 $1,082.00 $1,093.00 $649.00 $1,038.00 $1,629.00 $1,820.00 $1,078.00 $1,175.00 $964.00 $1,228.00 $1,168.00 $1,204.00 $1,271.00 $1,179.00 $1,834.00 $1,705.00 $1,996.00 $1,131.00 $1,480.00 $1,913.00 $1,378.00 $1,386.00 $1,815.00

$1,323.00 $2,471.00 $3,261.00 $78.00 $625.00 $919.00 $1,237.00 $887.00 $1,288.00 $693.00 $897.00 $1,101.00 $784.00 $975.00 $1,373.00 $959.00 $1,412.00 $1,082.00 $995.00 $1,047.00 $1,211.00 $1,487.00 $2,598.00 $2,149.00 $1,531.00 $1,290.00 $1,158.00 $1,154.00 $1,168.00 $693.00 $1,106.00 $1,738.00 $1,941.00 $1,150.00 $1,253.00 $1,029.00 $1,310.00 $1,247.00 $1,285.00 $1,356.00 $1,258.00 $1,956.00 $1,817.00 $2,128.00 $1,201.00 $1,578.00 $2,043.00 $1,471.00 $1,476.00 $1,935.00

$1,413.00 $2,675.00 $3,517.00 $82.00 $666.00 $978.00 $1,321.00 $942.00 $1,374.00 $737.00 $958.00 $1,173.00 $834.00 $1,026.00 $1,472.00 $1,025.00 $1,514.00 $1,158.00 $1,062.00 $1,117.00 $1,296.00 $1,593.00 $2,796.00 $2,309.00 $1,643.00 $1,380.00 $1,239.00 $1,233.00 $1,251.00 $738.00 $1,181.00 $1,861.00 $2,075.00 $1,228.00 $1,337.00 $1,102.00 $1,402.00 $1,338.00 $1,377.00 $1,452.00 $1,347.00 $2,101.00 $1,953.00 $2,288.00 $1,278.00 $1,690.00 $2,199.00 $1,578.00 $1,580.00 $2,078.00


Part B, 193



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90

$1,441.00 $1,613.00 $1,501.00 $1,665.00 $782.00 $938.00 $1,123.00 $797.00 $1,771.00 $2,352.00 $1,438.00 $1,477.00 $563.00 $652.00 $701.00 $782.00 $520.00 $659.00 $909.00 $911.00 $1,522.00 $1,297.00 $400.00 $649.00 $755.00 $1,281.00 $1,562.00 $1,508.00 $579.00 $820.00 $1,311.00 $266.00 $910.00 $408.00 $641.00 $1,075.00 $1,282.00 $487.00 $1,106.00 $296.00 $619.00 $832.00 $1,479.00 $1,529.00 $88.00 $514.00 $1,047.00 $184.00 $1,644.00 $1,059.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,728.00 $1,805.00 $1,724.00 $1,855.00 $966.00 $1,068.00 $1,150.00 $979.00 $2,068.00 $2,591.00 $1,762.00 $1,656.00 $786.00 $842.00 $942.00 $1,016.00 $749.00 $730.00 $1,119.00 $1,173.00 $1,965.00 $1,429.00 $756.00 $931.00 $996.00 $1,467.00 $1,830.00 $1,422.00 $731.00 $986.00 $1,312.00 $459.00 $1,098.00 $428.00 $890.00 $1,319.00 $1,747.00 $677.00 $1,182.00 $725.00 $909.00 $1,285.00 $1,546.00 $1,753.00 $516.00 $679.00 $1,305.00 $219.00 $2,109.00 $1,208.00

$1,842.00 $1,913.00 $1,839.00 $1,978.00 $1,032.00 $1,140.00 $1,213.00 $1,046.00 $2,205.00 $2,762.00 $1,879.00 $1,767.00 $840.00 $897.00 $1,006.00 $1,084.00 $799.00 $780.00 $1,192.00 $1,252.00 $2,096.00 $1,524.00 $807.00 $993.00 $1,062.00 $1,564.00 $1,952.00 $1,517.00 $782.00 $1,054.00 $1,401.00 $490.00 $1,172.00 $458.00 $950.00 $1,407.00 $1,864.00 $723.00 $1,261.00 $772.00 $970.00 $1,370.00 $1,651.00 $1,869.00 $549.00 $724.00 $1,393.00 $234.00 $2,250.00 $1,293.00

$1,975.00 $2,041.00 $1,973.00 $2,125.00 $1,104.00 $1,220.00 $1,285.00 $1,120.00 $2,369.00 $2,971.00 $2,017.00 $1,897.00 $895.00 $956.00 $1,076.00 $1,158.00 $848.00 $831.00 $1,276.00 $1,342.00 $2,251.00 $1,638.00 $854.00 $1,055.00 $1,135.00 $1,683.00 $2,103.00 $1,631.00 $828.00 $1,131.00 $1,508.00 $512.00 $1,254.00 $478.00 $1,010.00 $1,513.00 $2,001.00 $762.00 $1,349.00 $815.00 $1,035.00 $1,473.00 $1,781.00 $2,012.00 $576.00 $769.00 $1,493.00 $249.00 $2,415.00 $1,413.00

$1,728.00 $1,805.00 $1,724.00 $1,855.00 $966.00 $1,068.00 $1,150.00 $979.00 $2,068.00 $2,591.00 $1,762.00 $1,656.00 $786.00 $842.00 $942.00 $1,016.00 $697.00 $725.00 $1,119.00 $1,173.00 $1,965.00 $1,429.00 $715.00 $931.00 $996.00 $1,467.00 $1,830.00 $1,422.00 $689.00 $986.00 $1,312.00 $420.00 $1,098.00 $399.00 $839.00 $1,319.00 $1,747.00 $637.00 $1,182.00 $675.00 $909.00 $1,285.00 $1,546.00 $1,753.00 $478.00 $679.00 $1,305.00 $219.00 $2,109.00 $1,208.00

$1,842.00 $1,913.00 $1,839.00 $1,978.00 $1,032.00 $1,140.00 $1,213.00 $1,046.00 $2,205.00 $2,762.00 $1,879.00 $1,767.00 $840.00 $897.00 $1,006.00 $1,084.00 $743.00 $774.00 $1,192.00 $1,252.00 $2,096.00 $1,524.00 $762.00 $993.00 $1,062.00 $1,564.00 $1,952.00 $1,517.00 $737.00 $1,054.00 $1,401.00 $448.00 $1,172.00 $427.00 $895.00 $1,407.00 $1,864.00 $679.00 $1,261.00 $719.00 $970.00 $1,370.00 $1,651.00 $1,869.00 $508.00 $724.00 $1,393.00 $234.00 $2,250.00 $1,293.00

$1,975.00 $2,041.00 $1,973.00 $2,125.00 $1,104.00 $1,220.00 $1,285.00 $1,120.00 $2,369.00 $2,971.00 $2,017.00 $1,897.00 $895.00 $956.00 $1,076.00 $1,158.00 $792.00 $826.00 $1,276.00 $1,342.00 $2,251.00 $1,638.00 $809.00 $1,055.00 $1,135.00 $1,683.00 $2,103.00 $1,631.00 $783.00 $1,131.00 $1,508.00 $471.00 $1,254.00 $447.00 $955.00 $1,513.00 $2,001.00 $719.00 $1,349.00 $762.00 $1,035.00 $1,473.00 $1,781.00 $2,012.00 $535.00 $769.00 $1,493.00 $249.00 $2,415.00 $1,413.00


Part B, 194



90 90 90 90 90 YYY 90 90 90 90 90 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,182.00 $911.00 $600.00 $931.00 $976.00 BR $517.00 $516.00 $621.00 $412.00 $308.00 $236.00 $362.00 $608.00 $777.00 $701.00 $165.00 $327.00 $1,106.00 -------$421.00 $730.00 $587.00 $796.00 $863.00 $430.00 --------------$781.00 $921.00 $978.00 $1,122.00 $922.00 $1,302.00 $1,212.00 $1,044.00 $72.00 $869.00 $935.00 $937.00 $458.00 $527.00 $725.00 $504.00 $618.00 $656.00 $762.00 $523.00 $634.00 $565.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,415.00 $1,022.00 $752.00 $1,081.00 $1,077.00 -------$606.00 $649.00 $734.00 $760.00 $705.00 $481.00 $413.00 $886.00 $949.00 $806.00 $356.00 $825.00 $1,508.00 $1,877.00 $640.00 $683.00 $658.00 $851.00 $898.00 $797.00 $609.00 $1,009.00 $855.00 $1,091.00 $1,114.00 $1,220.00 $975.00 $2,618.00 $2,269.00 $1,482.00 $229.00 $955.00 $993.00 $1,027.00 $901.00 $539.00 $698.00 $521.00 $595.00 $705.00 $877.00 $623.00 $792.00 $946.00

$1,510.00 $1,093.00 $805.00 $1,157.00 $1,153.00 -------$648.00 $693.00 $786.00 $812.00 $752.00 $510.00 $438.00 $944.00 $1,010.00 $853.00 $379.00 $878.00 $1,609.00 $2,004.00 $684.00 $724.00 $699.00 $902.00 $952.00 $849.00 $651.00 $1,077.00 $910.00 $1,162.00 $1,186.00 $1,298.00 $1,035.00 $2,793.00 $2,424.00 $1,537.00 $244.00 $1,013.00 $1,048.00 $1,085.00 $964.00 $571.00 $738.00 $553.00 $631.00 $744.00 $930.00 $662.00 $846.00 $1,004.00

$1,622.00 $1,189.00 $868.00 $1,256.00 $1,250.00 -------$697.00 $743.00 $855.00 $854.00 $784.00 $522.00 $465.00 $1,006.00 $1,075.00 $898.00 $391.00 $916.00 $1,735.00 $2,165.00 $715.00 $767.00 $739.00 $955.00 $1,008.00 $880.00 $700.00 $1,157.00 $969.00 $1,237.00 $1,264.00 $1,386.00 $1,100.00 $3,010.00 $2,616.00 $1,592.00 $250.00 $1,070.00 $1,104.00 $1,144.00 $1,003.00 $600.00 $776.00 $582.00 $663.00 $782.00 $985.00 $700.00 $903.00 $1,040.00

$1,415.00 $1,022.00 $752.00 $1,081.00 $1,077.00 -------$606.00 $649.00 $734.00 $567.00 $502.00 $266.00 $413.00 $886.00 $949.00 $806.00 $235.00 $588.00 $1,508.00 $1,877.00 $447.00 $683.00 $658.00 $851.00 $898.00 $530.00 $609.00 $1,009.00 $855.00 $1,091.00 $1,114.00 $1,220.00 $975.00 $2,618.00 $2,269.00 $1,482.00 $77.00 $955.00 $993.00 $1,027.00 $574.00 $539.00 $698.00 $521.00 $595.00 $705.00 $877.00 $623.00 $792.00 $672.00

$1,510.00 $1,093.00 $805.00 $1,157.00 $1,153.00 -------$648.00 $693.00 $786.00 $606.00 $534.00 $279.00 $438.00 $944.00 $1,010.00 $853.00 $248.00 $624.00 $1,609.00 $2,004.00 $477.00 $724.00 $699.00 $902.00 $952.00 $563.00 $651.00 $1,077.00 $910.00 $1,162.00 $1,186.00 $1,298.00 $1,035.00 $2,793.00 $2,424.00 $1,537.00 $81.00 $1,013.00 $1,048.00 $1,085.00 $614.00 $571.00 $738.00 $553.00 $631.00 $744.00 $930.00 $662.00 $846.00 $710.00

$1,622.00 $1,189.00 $868.00 $1,256.00 $1,250.00 -------$697.00 $743.00 $855.00 $647.00 $565.00 $291.00 $465.00 $1,006.00 $1,075.00 $898.00 $260.00 $661.00 $1,735.00 $2,165.00 $508.00 $767.00 $739.00 $955.00 $1,008.00 $593.00 $700.00 $1,157.00 $969.00 $1,237.00 $1,264.00 $1,386.00 $1,100.00 $3,010.00 $2,616.00 $1,592.00 $87.00 $1,070.00 $1,104.00 $1,144.00 $652.00 $600.00 $776.00 $582.00 $663.00 $782.00 $985.00 $700.00 $903.00 $745.00


Part B, 195



90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$706.00 $589.00 $757.00 $889.00 $159.00 $658.00 $758.00 $881.00 $835.00 $1,278.00 $1,337.00 $683.00 $985.00 $484.00 $1,118.00 $1,227.00 $1,285.00 $1,147.00 $1,076.00 $1,402.00 $1,312.00 -------$1,175.00 $647.00 $611.00 $766.00 $1,044.00 $1,045.00 $940.00 $319.00 $614.00 $708.00 $1,115.00 $1,262.00 $223.00 $495.00 $759.00 ---------------------$244.00 $296.00 $643.00 $223.00 $422.00 $706.00 $332.00 $567.00 $972.00 $386.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$811.00 $657.00 $911.00 $1,089.00 $155.00 $688.00 $806.00 $933.00 $862.00 $1,414.00 $1,625.00 $839.00 $1,109.00 $583.00 $1,713.00 $1,614.00 $1,572.00 $1,280.00 $1,286.00 $1,861.00 $1,768.00 $1,420.00 $1,522.00 $831.00 $588.00 $958.00 $1,034.00 $1,121.00 $1,103.00 $493.00 $774.00 $831.00 $1,303.00 $1,465.00 $473.00 $680.00 $888.00 $399.00 $635.00 $1,067.00 $435.00 $604.00 $1,044.00 $449.00 $602.00 $951.00 $474.00 $668.00 $1,127.00 $454.00

$863.00 $696.00 $963.00 $1,157.00 $165.00 $728.00 $850.00 $988.00 $907.00 $1,504.00 $1,727.00 $893.00 $1,181.00 $622.00 $1,825.00 $1,721.00 $1,678.00 $1,365.00 $1,372.00 $1,985.00 $1,885.00 $1,514.00 $1,625.00 $887.00 $626.00 $1,023.00 $1,105.00 $1,190.00 $1,176.00 $526.00 $826.00 $887.00 $1,390.00 $1,563.00 $504.00 $724.00 $947.00 $426.00 $679.00 $1,139.00 $464.00 $644.00 $1,114.00 $478.00 $641.00 $1,014.00 $506.00 $712.00 $1,202.00 $484.00

$916.00 $733.00 $1,013.00 $1,227.00 $177.00 $767.00 $894.00 $1,046.00 $951.00 $1,607.00 $1,844.00 $950.00 $1,260.00 $659.00 $1,957.00 $1,845.00 $1,803.00 $1,460.00 $1,470.00 $2,135.00 $2,019.00 $1,625.00 $1,746.00 $947.00 $663.00 $1,095.00 $1,183.00 $1,257.00 $1,258.00 $552.00 $875.00 $943.00 $1,489.00 $1,678.00 $526.00 $762.00 $1,009.00 $445.00 $720.00 $1,219.00 $485.00 $678.00 $1,190.00 $500.00 $674.00 $1,081.00 $527.00 $749.00 $1,284.00 $506.00

$811.00 $657.00 $911.00 $1,089.00 $155.00 $688.00 $806.00 $933.00 $862.00 $1,414.00 $1,625.00 $839.00 $1,109.00 $583.00 $1,713.00 $1,614.00 $1,572.00 $1,280.00 $1,286.00 $1,861.00 $1,768.00 $1,420.00 $1,522.00 $831.00 $588.00 $958.00 $1,034.00 $1,121.00 $1,103.00 $454.00 $718.00 $831.00 $1,303.00 $1,465.00 $434.00 $623.00 $888.00 $402.00 $635.00 $1,067.00 $397.00 $562.00 $1,044.00 $408.00 $553.00 $951.00 $428.00 $610.00 $1,127.00 $410.00

$863.00 $696.00 $963.00 $1,157.00 $165.00 $728.00 $850.00 $988.00 $907.00 $1,504.00 $1,727.00 $893.00 $1,181.00 $622.00 $1,825.00 $1,721.00 $1,678.00 $1,365.00 $1,372.00 $1,985.00 $1,885.00 $1,514.00 $1,625.00 $887.00 $626.00 $1,023.00 $1,105.00 $1,190.00 $1,176.00 $485.00 $766.00 $887.00 $1,390.00 $1,563.00 $462.00 $663.00 $947.00 $428.00 $679.00 $1,139.00 $424.00 $600.00 $1,114.00 $435.00 $589.00 $1,014.00 $456.00 $649.00 $1,202.00 $436.00

$916.00 $733.00 $1,013.00 $1,227.00 $177.00 $767.00 $894.00 $1,046.00 $951.00 $1,607.00 $1,844.00 $950.00 $1,260.00 $659.00 $1,957.00 $1,845.00 $1,803.00 $1,460.00 $1,470.00 $2,135.00 $2,019.00 $1,625.00 $1,746.00 $947.00 $663.00 $1,095.00 $1,183.00 $1,257.00 $1,258.00 $510.00 $815.00 $943.00 $1,489.00 $1,678.00 $484.00 $701.00 $1,009.00 $447.00 $720.00 $1,219.00 $444.00 $633.00 $1,190.00 $456.00 $621.00 $1,081.00 $478.00 $686.00 $1,284.00 $458.00


Part B, 196



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$613.00 $1,201.00 $1,472.00 $384.00 $670.00 $1,080.00 $1,310.00 $1,823.00 $742.00 $412.00 $415.00 $617.00 $334.00 $373.00 $877.00 $1,224.00 $211.00 $1,269.00 $843.00 $1,015.00 $1,120.00 $854.00 $579.00 $835.00 $911.00 $879.00 $575.00 $574.00 $712.00 BR $185.00 $362.00 $520.00 $520.00 $296.00 $235.00 $340.00 $509.00 $422.00 $371.00 $532.00 --------------$305.00 $456.00 $814.00 -------$414.00 $402.00 $236.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$693.00 $1,225.00 $1,394.00 $448.00 $785.00 $1,211.00 $1,577.00 $1,896.00 $993.00 $545.00 $567.00 $1,105.00 $529.00 $719.00 $1,059.00 $1,186.00 $254.00 $1,508.00 $997.00 $1,381.00 $1,297.00 $904.00 $861.00 $984.00 $1,010.00 $979.00 $810.00 $881.00 $1,259.00 -------$393.00 $633.00 $1,017.00 $836.00 $615.00 $331.00 $461.00 $773.00 $697.00 $657.00 $751.00 $731.00 $669.00 $569.00 $707.00 $1,062.00 $1,571.00 $604.00 $639.00 $556.00

$738.00 $1,306.00 $1,486.00 $478.00 $837.00 $1,291.00 $1,683.00 $2,022.00 $1,059.00 $583.00 $606.00 $1,180.00 $562.00 $767.00 $1,127.00 $1,263.00 $270.00 $1,604.00 $1,062.00 $1,478.00 $1,386.00 $967.00 $922.00 $1,053.00 $1,077.00 $1,047.00 $864.00 $941.00 $1,344.00 -------$414.00 $667.00 $1,073.00 $877.00 $648.00 $348.00 $486.00 $821.00 $737.00 $695.00 $796.00 $774.00 $704.00 $601.00 $746.00 $1,116.00 $1,665.00 $636.00 $677.00 $588.00

$777.00 $1,392.00 $1,587.00 $502.00 $887.00 $1,375.00 $1,797.00 $2,165.00 $1,126.00 $615.00 $645.00 $1,263.00 $592.00 $815.00 $1,202.00 $1,350.00 $286.00 $1,712.00 $1,131.00 $1,613.00 $1,500.00 $1,054.00 $999.00 $1,140.00 $1,157.00 $1,142.00 $925.00 $1,006.00 $1,447.00 -------$424.00 $687.00 $1,112.00 $913.00 $664.00 $357.00 $502.00 $849.00 $758.00 $713.00 $820.00 $801.00 $738.00 $616.00 $765.00 $1,171.00 $1,775.00 $649.00 $696.00 $600.00

$625.00 $1,225.00 $1,394.00 $436.00 $717.00 $1,211.00 $1,577.00 $1,896.00 $993.00 $510.00 $567.00 $1,105.00 $529.00 $719.00 $1,059.00 $1,186.00 $254.00 $1,508.00 $997.00 $1,381.00 $1,297.00 $904.00 $861.00 $984.00 $1,010.00 $979.00 $810.00 $881.00 $1,259.00 -------$244.00 $460.00 $821.00 $836.00 $421.00 $299.00 $414.00 $524.00 $469.00 $439.00 $512.00 $509.00 $669.00 $377.00 $501.00 $1,062.00 $1,571.00 $401.00 $412.00 $351.00

$665.00 $1,306.00 $1,486.00 $465.00 $763.00 $1,291.00 $1,683.00 $2,022.00 $1,059.00 $545.00 $606.00 $1,180.00 $562.00 $767.00 $1,127.00 $1,263.00 $270.00 $1,604.00 $1,062.00 $1,478.00 $1,386.00 $967.00 $922.00 $1,053.00 $1,077.00 $1,047.00 $864.00 $941.00 $1,344.00 -------$255.00 $482.00 $862.00 $877.00 $441.00 $314.00 $435.00 $553.00 $493.00 $461.00 $539.00 $536.00 $704.00 $396.00 $524.00 $1,116.00 $1,665.00 $419.00 $434.00 $368.00

$704.00 $1,392.00 $1,587.00 $489.00 $813.00 $1,375.00 $1,797.00 $2,165.00 $1,126.00 $578.00 $645.00 $1,263.00 $592.00 $815.00 $1,202.00 $1,350.00 $286.00 $1,712.00 $1,131.00 $1,613.00 $1,500.00 $1,054.00 $999.00 $1,140.00 $1,157.00 $1,142.00 $925.00 $1,006.00 $1,447.00 -------$264.00 $502.00 $901.00 $913.00 $456.00 $323.00 $451.00 $580.00 $513.00 $478.00 $563.00 $562.00 $738.00 $410.00 $543.00 $1,171.00 $1,775.00 $431.00 $453.00 $379.00


Part B, 197



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90

-------$495.00 $657.00 $476.00 $445.00 $392.00 $462.00 $414.00 $414.00 $330.00 $571.00 $700.00 $709.00 $491.00 $632.00 $517.00 $418.00 $421.00 $537.00 $457.00 $481.00 $890.00 $648.00 $568.00 $524.00 $601.00 $622.00 $480.00 $393.00 $727.00 $533.00 $416.00 $400.00 $412.00 $789.00 $747.00 $571.00 $75.00 $326.00 $341.00 $478.00 $613.00 $406.00 $609.00 $435.00 $555.00 $345.00 $334.00 $380.00 $286.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$541.00 $740.00 $837.00 $762.00 $723.00 $745.00 $784.00 $638.00 $671.00 $602.00 $869.00 $881.00 $564.00 $754.00 $670.00 $797.00 $627.00 $659.00 $706.00 $698.00 $844.00 $1,544.00 $1,084.00 $850.00 $750.00 $973.00 $857.00 $679.00 $563.00 $930.00 $861.00 $610.00 $585.00 $600.00 $1,227.00 $1,107.00 $706.00 $363.00 $673.00 $757.00 $699.00 $854.00 $676.00 $820.00 $641.00 $722.00 $583.00 $869.00 $620.00 $551.00

$564.00 $783.00 $883.00 $807.00 $767.00 $789.00 $834.00 $677.00 $710.00 $637.00 $923.00 $941.00 $588.00 $798.00 $703.00 $843.00 $663.00 $698.00 $747.00 $739.00 $892.00 $1,637.00 $1,144.00 $901.00 $792.00 $1,032.00 $905.00 $716.00 $596.00 $983.00 $912.00 $645.00 $619.00 $635.00 $1,273.00 $1,154.00 $737.00 $385.00 $711.00 $799.00 $740.00 $900.00 $716.00 $865.00 $677.00 $761.00 $617.00 $930.00 $655.00 $583.00

$584.00 $805.00 $906.00 $832.00 $790.00 $808.00 $863.00 $696.00 $729.00 $652.00 $955.00 $1,003.00 $607.00 $822.00 $733.00 $866.00 $679.00 $715.00 $770.00 $760.00 $915.00 $1,701.00 $1,183.00 $931.00 $814.00 $1,071.00 $933.00 $733.00 $609.00 $1,035.00 $948.00 $662.00 $633.00 $650.00 $1,318.00 $1,201.00 $764.00 $393.00 $730.00 $820.00 $760.00 $925.00 $735.00 $890.00 $693.00 $779.00 $632.00 $969.00 $670.00 $596.00

$541.00 $515.00 $588.00 $514.00 $479.00 $525.00 $523.00 $407.00 $444.00 $386.00 $597.00 $881.00 $564.00 $510.00 $670.00 $539.00 $414.00 $416.00 $473.00 $452.00 $611.00 $1,213.00 $826.00 $598.00 $520.00 $722.00 $635.00 $474.00 $357.00 $930.00 $642.00 $405.00 $378.00 $388.00 $1,227.00 $1,107.00 $706.00 $192.00 $453.00 $531.00 $463.00 $615.00 $449.00 $590.00 $433.00 $502.00 $373.00 $569.00 $407.00 $349.00

$564.00 $541.00 $615.00 $541.00 $506.00 $553.00 $554.00 $429.00 $467.00 $406.00 $631.00 $941.00 $588.00 $537.00 $703.00 $566.00 $434.00 $437.00 $497.00 $476.00 $642.00 $1,281.00 $867.00 $630.00 $546.00 $763.00 $667.00 $496.00 $375.00 $983.00 $676.00 $425.00 $397.00 $408.00 $1,273.00 $1,154.00 $737.00 $202.00 $476.00 $556.00 $487.00 $644.00 $472.00 $618.00 $454.00 $524.00 $391.00 $607.00 $426.00 $366.00

$584.00 $562.00 $637.00 $565.00 $528.00 $571.00 $583.00 $447.00 $485.00 $420.00 $662.00 $1,003.00 $607.00 $560.00 $733.00 $588.00 $449.00 $454.00 $519.00 $495.00 $665.00 $1,345.00 $906.00 $660.00 $566.00 $800.00 $695.00 $512.00 $388.00 $1,035.00 $712.00 $441.00 $410.00 $422.00 $1,318.00 $1,201.00 $764.00 $209.00 $494.00 $576.00 $507.00 $668.00 $491.00 $643.00 $469.00 $542.00 $406.00 $645.00 $441.00 $378.00


Part B, 198



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$178.00 $695.00 $370.00 $535.00 $641.00 $881.00 $1,363.00 $912.00 $266.00 $336.00 $426.00 $463.00 $441.00 $452.00 $458.00 $557.00 $666.00 $845.00 $797.00 $832.00 $838.00 $755.00 $829.00 $845.00 $930.00 $776.00 $1,030.00 $530.00 $614.00 $516.00 $955.00 $505.00 $469.00 $436.00 $462.00 $833.00 $667.00 $649.00 $753.00 $414.00 $557.00 $1,197.00 $266.00 $473.00 $616.00 $1,354.00 $1,619.00 $110.00 $371.00 $463.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$581.00 $962.00 $630.00 $834.00 $986.00 $1,412.00 $2,138.00 $1,448.00 $701.00 $562.00 $740.00 $763.00 $644.00 $863.00 $1,050.00 $842.00 $1,127.00 $1,493.00 $1,102.00 $1,019.00 $1,165.00 $1,034.00 $1,287.00 $950.00 $1,046.00 $1,188.00 $968.00 $879.00 $976.00 $807.00 $1,322.00 $782.00 $726.00 $757.00 $688.00 $887.00 $1,137.00 $827.00 $960.00 $672.00 $745.00 $1,342.00 $354.00 $565.00 $757.00 $1,614.00 $1,840.00 $337.00 $455.00 $648.00

$615.00 $1,015.00 $665.00 $884.00 $1,042.00 $1,488.00 $2,284.00 $1,548.00 $741.00 $593.00 $783.00 $806.00 $680.00 $914.00 $1,111.00 $893.00 $1,189.00 $1,573.00 $1,166.00 $1,074.00 $1,232.00 $1,092.00 $1,355.00 $1,007.00 $1,117.00 $1,260.00 $1,018.00 $932.00 $1,037.00 $855.00 $1,399.00 $827.00 $769.00 $803.00 $727.00 $937.00 $1,208.00 $868.00 $1,008.00 $715.00 $784.00 $1,416.00 $376.00 $599.00 $805.00 $1,715.00 $1,965.00 $359.00 $483.00 $692.00

$629.00 $1,048.00 $682.00 $915.00 $1,080.00 $1,544.00 $2,425.00 $1,633.00 $761.00 $605.00 $806.00 $828.00 $695.00 $940.00 $1,150.00 $921.00 $1,222.00 $1,609.00 $1,206.00 $1,103.00 $1,276.00 $1,127.00 $1,400.00 $1,067.00 $1,196.00 $1,311.00 $1,070.00 $964.00 $1,074.00 $879.00 $1,483.00 $850.00 $789.00 $829.00 $746.00 $988.00 $1,260.00 $889.00 $1,032.00 $743.00 $801.00 $1,497.00 $391.00 $626.00 $852.00 $1,824.00 $2,109.00 $373.00 $503.00 $732.00

$378.00 $705.00 $418.00 $588.00 $740.00 $1,126.00 $1,739.00 $1,117.00 $480.00 $365.00 $506.00 $543.00 $431.00 $619.00 $791.00 $572.00 $865.00 $1,021.00 $794.00 $750.00 $844.00 $732.00 $980.00 $950.00 $1,046.00 $881.00 $968.00 $585.00 $653.00 $543.00 $1,322.00 $517.00 $460.00 $519.00 $469.00 $887.00 $842.00 $595.00 $709.00 $454.00 $524.00 $1,342.00 $325.00 $515.00 $757.00 $1,614.00 $1,840.00 $301.00 $408.00 $648.00

$397.00 $740.00 $438.00 $621.00 $778.00 $1,181.00 $1,857.00 $1,192.00 $504.00 $382.00 $531.00 $570.00 $450.00 $651.00 $832.00 $603.00 $907.00 $1,066.00 $835.00 $786.00 $887.00 $769.00 $1,026.00 $1,007.00 $1,117.00 $931.00 $1,018.00 $618.00 $691.00 $572.00 $1,399.00 $543.00 $484.00 $548.00 $492.00 $937.00 $891.00 $619.00 $738.00 $482.00 $547.00 $1,416.00 $346.00 $545.00 $805.00 $1,715.00 $1,965.00 $321.00 $433.00 $692.00

$410.00 $772.00 $453.00 $651.00 $815.00 $1,237.00 $1,996.00 $1,277.00 $523.00 $394.00 $553.00 $591.00 $465.00 $677.00 $870.00 $630.00 $939.00 $1,101.00 $874.00 $814.00 $930.00 $803.00 $1,071.00 $1,067.00 $1,196.00 $981.00 $1,070.00 $648.00 $727.00 $595.00 $1,483.00 $565.00 $503.00 $573.00 $511.00 $988.00 $942.00 $639.00 $762.00 $509.00 $564.00 $1,497.00 $360.00 $573.00 $852.00 $1,824.00 $2,109.00 $335.00 $453.00 $732.00


Part B, 199



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90

$874.00 -------$148.00 $321.00 $288.00 $533.00 $178.00 $296.00 $364.00 $521.00 $80.00 $133.00 $261.00 $399.00 $75.00 $115.00 $345.00 $120.00 $243.00 $145.00 $208.00 $325.00 $592.00 $189.00 $308.00 $382.00 $742.00 $144.00 $287.00 $487.00 $621.00 $145.00 $189.00 $318.00 $434.00 $106.00 $172.00 $309.00 $348.00 $1,353.00 $1,179.00 $1,015.00 $945.00 $961.00 $873.00 $690.00 $690.00 $466.00 $654.00 $731.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,553.00 $1,777.00 $307.00 $412.00 $457.00 $904.00 $312.00 $367.00 $504.00 $758.00 $206.00 $252.00 $620.00 $957.00 $176.00 $229.00 $809.00 $163.00 $489.00 $294.00 $417.00 $792.00 $1,269.00 $317.00 $524.00 $564.00 $1,227.00 $310.00 $466.00 $572.00 $1,146.00 $224.00 $249.00 $403.00 $942.00 $166.00 $220.00 $271.00 $835.00 $1,835.00 $1,367.00 $1,133.00 $1,066.00 $1,138.00 $1,001.00 $1,216.00 $1,168.00 $726.00 $1,132.00 $792.00

$1,650.00 $1,896.00 $326.00 $436.00 $489.00 $958.00 $331.00 $389.00 $537.00 $800.00 $219.00 $267.00 $661.00 $1,013.00 $186.00 $242.00 $857.00 $173.00 $518.00 $311.00 $445.00 $848.00 $1,349.00 $338.00 $560.00 $603.00 $1,292.00 $330.00 $498.00 $608.00 $1,218.00 $237.00 $263.00 $425.00 $996.00 $176.00 $232.00 $287.00 $886.00 $1,942.00 $1,453.00 $1,202.00 $1,129.00 $1,202.00 $1,054.00 $1,290.00 $1,240.00 $769.00 $1,196.00 $836.00

$1,758.00 $2,035.00 $338.00 $451.00 $513.00 $1,010.00 $344.00 $404.00 $561.00 $836.00 $225.00 $274.00 $677.00 $1,050.00 $192.00 $249.00 $884.00 $178.00 $526.00 $320.00 $466.00 $874.00 $1,411.00 $352.00 $589.00 $639.00 $1,335.00 $341.00 $522.00 $642.00 $1,288.00 $246.00 $271.00 $434.00 $1,029.00 $183.00 $240.00 $302.00 $916.00 $2,066.00 $1,543.00 $1,274.00 $1,193.00 $1,269.00 $1,107.00 $1,340.00 $1,288.00 $791.00 $1,236.00 $882.00

$1,553.00 $1,777.00 $275.00 $373.00 $457.00 $904.00 $292.00 $327.00 $504.00 $758.00 $178.00 $213.00 $335.00 $723.00 $171.00 $203.00 $575.00 $146.00 $263.00 $266.00 $372.00 $473.00 $974.00 $270.00 $476.00 $564.00 $970.00 $268.00 $421.00 $572.00 $1,146.00 $159.00 $189.00 $261.00 $702.00 $128.00 $188.00 $271.00 $594.00 $1,835.00 $1,367.00 $1,133.00 $1,066.00 $1,138.00 $1,001.00 $904.00 $858.00 $477.00 $835.00 $792.00

$1,650.00 $1,896.00 $292.00 $394.00 $489.00 $958.00 $310.00 $346.00 $537.00 $800.00 $189.00 $225.00 $356.00 $762.00 $182.00 $214.00 $606.00 $154.00 $276.00 $281.00 $397.00 $505.00 $1,033.00 $288.00 $509.00 $603.00 $1,016.00 $285.00 $450.00 $608.00 $1,218.00 $168.00 $199.00 $274.00 $738.00 $136.00 $198.00 $287.00 $628.00 $1,942.00 $1,453.00 $1,202.00 $1,129.00 $1,202.00 $1,054.00 $955.00 $907.00 $502.00 $878.00 $836.00

$1,758.00 $2,035.00 $304.00 $408.00 $513.00 $1,010.00 $323.00 $361.00 $561.00 $836.00 $195.00 $233.00 $370.00 $798.00 $187.00 $221.00 $631.00 $158.00 $284.00 $290.00 $417.00 $531.00 $1,094.00 $302.00 $538.00 $639.00 $1,059.00 $296.00 $474.00 $642.00 $1,288.00 $176.00 $207.00 $282.00 $770.00 $142.00 $206.00 $302.00 $657.00 $2,066.00 $1,543.00 $1,274.00 $1,193.00 $1,269.00 $1,107.00 $1,005.00 $954.00 $523.00 $916.00 $882.00


Part B, 200



90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$731.00 $543.00 $377.00 $339.00 -------BR $247.00 $271.00 $289.00 $213.00 $260.00 $260.00 $286.00 $45.00 $180.00 $110.00 $88.00 $72.00 $59.00 $54.00 $59.00 $45.00 $53.00 $26.00 $53.00 $29.00 $45.00 $26.00 $29.00 $223.00 $260.00 $126.00 $133.00 $241.00 $101.00 $96.00 $101.00 $133.00 $22.00 $214.00 $84.00 $75.00 $59.00 $22.00 $55.00 $41.00 $37.00 $39.00 ---------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,079.00 $635.00 $813.00 $774.00 $459.00 -------$414.00 $338.00 $404.00 $276.00 $321.00 $398.00 $345.00 $120.00 $317.00 $175.00 $137.00 $123.00 $136.00 $110.00 $125.00 $91.00 $108.00 $59.00 $72.00 $42.00 $41.00 $41.00 $42.00 $352.00 $388.00 $195.00 $202.00 $229.00 $175.00 $116.00 $112.00 $166.00 $62.00 $192.00 $205.00 $118.00 $102.00 $44.00 $41.00 $37.00 $27.00 $75.00 $85.00 $97.00

$1,140.00 $674.00 $863.00 $822.00 $484.00 -------$447.00 $360.00 $431.00 $293.00 $340.00 $423.00 $367.00 $128.00 $339.00 $187.00 $146.00 $132.00 $145.00 $117.00 $133.00 $97.00 $115.00 $62.00 $76.00 $43.00 $42.00 $44.00 $44.00 $377.00 $416.00 $208.00 $215.00 $245.00 $187.00 $124.00 $119.00 $177.00 $65.00 $203.00 $215.00 $125.00 $108.00 $46.00 $43.00 $39.00 $28.00 $79.00 $90.00 $103.00

$1,213.00 $719.00 $895.00 $851.00 $497.00 -------$476.00 $374.00 $447.00 $303.00 $353.00 $434.00 $380.00 $134.00 $354.00 $196.00 $153.00 $137.00 $151.00 $121.00 $138.00 $100.00 $119.00 $65.00 $79.00 $44.00 $43.00 $45.00 $46.00 $393.00 $435.00 $219.00 $227.00 $257.00 $196.00 $129.00 $123.00 $185.00 $67.00 $211.00 $223.00 $129.00 $112.00 $47.00 $44.00 $40.00 $29.00 $82.00 $91.00 $103.00

$1,079.00 $635.00 $577.00 $540.00 $322.00 -------$260.00 $214.00 $259.00 $174.00 $211.00 $218.00 $230.00 $91.00 $203.00 $135.00 $99.00 $90.00 $98.00 $73.00 $86.00 $57.00 $70.00 $42.00 $48.00 $26.00 $27.00 $28.00 $29.00 $232.00 $260.00 $147.00 $155.00 $152.00 $128.00 $87.00 $82.00 $120.00 $42.00 $151.00 $163.00 $72.00 $71.00 $27.00 $27.00 $26.00 $17.00 $51.00 $18.00 $23.00

$1,140.00 $674.00 $609.00 $570.00 $338.00 -------$282.00 $228.00 $275.00 $184.00 $223.00 $230.00 $243.00 $96.00 $217.00 $144.00 $106.00 $96.00 $104.00 $78.00 $91.00 $60.00 $74.00 $44.00 $50.00 $27.00 $27.00 $30.00 $31.00 $248.00 $278.00 $157.00 $165.00 $163.00 $136.00 $92.00 $87.00 $128.00 $43.00 $159.00 $170.00 $76.00 $75.00 $27.00 $28.00 $27.00 $17.00 $54.00 $19.00 $23.00

$1,213.00 $719.00 $640.00 $598.00 $350.00 -------$310.00 $242.00 $291.00 $193.00 $235.00 $241.00 $256.00 $102.00 $231.00 $153.00 $112.00 $102.00 $110.00 $81.00 $96.00 $63.00 $77.00 $47.00 $53.00 $28.00 $28.00 $31.00 $32.00 $264.00 $298.00 $167.00 $176.00 $174.00 $145.00 $97.00 $91.00 $136.00 $45.00 $166.00 $178.00 $80.00 $79.00 $28.00 $29.00 $28.00 $18.00 $57.00 $19.00 $23.00


Part B, 201



0 0 0 0 0 0 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

--------------$29.00 $26.00 $29.00 $29.00 $29.00 $37.00 $105.00 BR $557.00 $902.00 $360.00 $1,003.00 $976.00 $756.00 $718.00 $863.00 $749.00 $1,330.00 $611.00 $941.00 $980.00 $1,058.00 -------$524.00 $635.00 $612.00 $680.00 $830.00 $931.00 $501.00 $580.00 $612.00 $931.00 $976.00 $1,277.00 $608.00 $752.00 $1,137.00 $1,007.00 $1,231.00 $658.00 $845.00 $907.00 $880.00 ---------------------$460.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$60.00 $97.00 $89.00 $96.00 $175.00 $121.00 $93.00 $143.00 $128.00 -------$741.00 $940.00 $687.00 $1,557.00 $1,519.00 $855.00 $776.00 $848.00 $823.00 $898.00 $968.00 $839.00 $261.00 $1,541.00 $1,329.00 $658.00 $704.00 $737.00 $825.00 $759.00 $853.00 $658.00 $705.00 $717.00 $833.00 $753.00 $772.00 $740.00 $900.00 $1,294.00 $1,143.00 $1,463.00 $964.00 $1,049.00 $1,174.00 $1,174.00 $1,527.00 $1,856.00 $2,363.00 $834.00

$64.00 $103.00 $95.00 $102.00 $187.00 $129.00 $99.00 $153.00 $135.00 -------$788.00 $1,000.00 $734.00 $1,662.00 $1,622.00 $913.00 $826.00 $902.00 $874.00 $954.00 $1,029.00 $892.00 $279.00 $1,636.00 $1,413.00 $700.00 $749.00 $787.00 $877.00 $808.00 $908.00 $703.00 $753.00 $762.00 $886.00 $802.00 $819.00 $789.00 $959.00 $1,375.00 $1,219.00 $1,563.00 $1,029.00 $1,116.00 $1,248.00 $1,249.00 $1,629.00 $1,981.00 $2,515.00 $891.00

$65.00 $103.00 $98.00 $107.00 $197.00 $135.00 $103.00 $163.00 $141.00 -------$834.00 $1,061.00 $783.00 $1,784.00 $1,740.00 $976.00 $876.00 $956.00 $926.00 $1,010.00 $1,089.00 $944.00 $302.00 $1,739.00 $1,503.00 $743.00 $792.00 $841.00 $928.00 $857.00 $966.00 $750.00 $803.00 $807.00 $937.00 $850.00 $866.00 $837.00 $1,023.00 $1,467.00 $1,303.00 $1,679.00 $1,099.00 $1,188.00 $1,325.00 $1,326.00 $1,745.00 $2,128.00 $2,701.00 $934.00

$16.00 $23.00 $49.00 $69.00 $122.00 $65.00 $66.00 $104.00 $98.00 -------$741.00 $940.00 $687.00 $1,557.00 $1,519.00 $855.00 $776.00 $848.00 $823.00 $898.00 $968.00 $839.00 $261.00 $1,541.00 $1,329.00 $658.00 $704.00 $737.00 $825.00 $759.00 $853.00 $658.00 $705.00 $717.00 $833.00 $753.00 $772.00 $740.00 $900.00 $1,294.00 $1,143.00 $1,463.00 $964.00 $1,049.00 $1,174.00 $1,174.00 $1,527.00 $1,856.00 $2,363.00 $600.00

$16.00 $23.00 $52.00 $74.00 $130.00 $70.00 $70.00 $111.00 $103.00 -------$788.00 $1,000.00 $734.00 $1,662.00 $1,622.00 $913.00 $826.00 $902.00 $874.00 $954.00 $1,029.00 $892.00 $279.00 $1,636.00 $1,413.00 $700.00 $749.00 $787.00 $877.00 $808.00 $908.00 $703.00 $753.00 $762.00 $886.00 $802.00 $819.00 $789.00 $959.00 $1,375.00 $1,219.00 $1,563.00 $1,029.00 $1,116.00 $1,248.00 $1,249.00 $1,629.00 $1,981.00 $2,515.00 $641.00

$17.00 $23.00 $55.00 $79.00 $141.00 $75.00 $75.00 $120.00 $109.00 -------$834.00 $1,061.00 $783.00 $1,784.00 $1,740.00 $976.00 $876.00 $956.00 $926.00 $1,010.00 $1,089.00 $944.00 $302.00 $1,739.00 $1,503.00 $743.00 $792.00 $841.00 $928.00 $857.00 $966.00 $750.00 $803.00 $807.00 $937.00 $850.00 $866.00 $837.00 $1,023.00 $1,467.00 $1,303.00 $1,679.00 $1,099.00 $1,188.00 $1,325.00 $1,326.00 $1,745.00 $2,128.00 $2,701.00 $682.00


Part B, 202



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 0 10 90 90 90 90 90 90 90 90 90 90

$631.00 $489.00 $676.00 $639.00 $809.00 $852.00 $1,064.00 $1,169.00 $745.00 $819.00 $1,235.00 $721.00 $832.00 $697.00 $949.00 $1,296.00 $1,255.00 $796.00 $835.00 $472.00 $690.00 $679.00 $704.00 $863.00 $973.00 $434.00 $479.00 $514.00 -------------------------------------------------BR $96.00 $117.00 $86.00 $157.00 $360.00 $301.00 $819.00 $500.00 $243.00 $599.00 $275.00 $320.00 $790.00 $875.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$750.00 $761.00 $783.00 $721.00 $962.00 $908.00 $967.00 $819.00 $789.00 $1,025.00 $1,232.00 $894.00 $1,098.00 $931.00 $1,092.00 $1,446.00 $1,793.00 $984.00 $840.00 $868.00 $729.00 $693.00 $738.00 $823.00 $1,517.00 $650.00 $774.00 $810.00 $933.00 $1,001.00 $1,053.00 $1,285.00 $1,454.00 $1,478.00 $1,480.00 -------$323.00 $328.00 $199.00 $325.00 $617.00 $1,223.00 $1,106.00 $740.00 $409.00 $872.00 $540.00 $624.00 $1,107.00 $1,111.00

$802.00 $814.00 $836.00 $770.00 $1,028.00 $969.00 $1,032.00 $874.00 $842.00 $1,095.00 $1,314.00 $952.00 $1,172.00 $995.00 $1,166.00 $1,543.00 $1,914.00 $1,044.00 $875.00 $915.00 $772.00 $733.00 $782.00 $871.00 $1,614.00 $685.00 $827.00 $860.00 $997.00 $1,069.00 $1,124.00 $1,372.00 $1,545.00 $1,570.00 $1,572.00 -------$345.00 $350.00 $212.00 $346.00 $655.00 $1,308.00 $1,173.00 $787.00 $434.00 $925.00 $574.00 $664.00 $1,176.00 $1,178.00

$856.00 $865.00 $892.00 $821.00 $1,099.00 $1,033.00 $1,103.00 $931.00 $897.00 $1,173.00 $1,407.00 $1,010.00 $1,253.00 $1,064.00 $1,248.00 $1,654.00 $2,053.00 $1,106.00 $905.00 $934.00 $817.00 $773.00 $829.00 $921.00 $1,724.00 $708.00 $881.00 $906.00 $1,067.00 $1,143.00 $1,201.00 $1,471.00 $1,646.00 $1,670.00 $1,672.00 -------$354.00 $359.00 $217.00 $356.00 $681.00 $1,329.00 $1,231.00 $821.00 $452.00 $969.00 $594.00 $686.00 $1,235.00 $1,238.00

$750.00 $761.00 $783.00 $721.00 $962.00 $908.00 $967.00 $819.00 $789.00 $1,025.00 $1,232.00 $894.00 $1,098.00 $931.00 $1,092.00 $1,446.00 $1,793.00 $984.00 $840.00 $612.00 $729.00 $693.00 $738.00 $823.00 $1,517.00 $650.00 $774.00 $810.00 $933.00 $1,001.00 $1,053.00 $1,285.00 $1,454.00 $1,478.00 $1,480.00 -------$170.00 $171.00 $99.00 $188.00 $617.00 $485.00 $1,106.00 $630.00 $409.00 $872.00 $540.00 $624.00 $1,107.00 $1,111.00

$802.00 $814.00 $836.00 $770.00 $1,028.00 $969.00 $1,032.00 $874.00 $842.00 $1,095.00 $1,314.00 $952.00 $1,172.00 $995.00 $1,166.00 $1,543.00 $1,914.00 $1,044.00 $875.00 $641.00 $772.00 $733.00 $782.00 $871.00 $1,614.00 $685.00 $827.00 $860.00 $997.00 $1,069.00 $1,124.00 $1,372.00 $1,545.00 $1,570.00 $1,572.00 -------$180.00 $182.00 $105.00 $199.00 $655.00 $516.00 $1,173.00 $669.00 $434.00 $925.00 $574.00 $664.00 $1,176.00 $1,178.00

$856.00 $865.00 $892.00 $821.00 $1,099.00 $1,033.00 $1,103.00 $931.00 $897.00 $1,173.00 $1,407.00 $1,010.00 $1,253.00 $1,064.00 $1,248.00 $1,654.00 $2,053.00 $1,106.00 $905.00 $660.00 $817.00 $773.00 $829.00 $921.00 $1,724.00 $708.00 $881.00 $906.00 $1,067.00 $1,143.00 $1,201.00 $1,471.00 $1,646.00 $1,670.00 $1,672.00 -------$188.00 $191.00 $110.00 $208.00 $681.00 $535.00 $1,231.00 $703.00 $452.00 $969.00 $594.00 $686.00 $1,235.00 $1,238.00


Part B, 203



0 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 10 10 0 0 0 0 90 90 10 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$68.00 $75.00 $154.00 $45.00 $170.00 $419.00 $741.00 $1,173.00 $1,424.00 $626.00 $1,005.00 $1,445.00 $857.00 $1,633.00 $803.00 $533.00 $643.00 $981.00 $104.00 $566.00 $466.00 $564.00 $624.00 $88.00 $172.00 $75.00 $110.00 $224.00 $208.00 $596.00 $862.00 $213.00 BR $81.00 $135.00 $281.00 $531.00 $604.00 $772.00 $489.00 $654.00 $410.00 $839.00 $942.00 $1,089.00 $1,210.00 $1,281.00 $1,081.00 $1,075.00 $877.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$160.00 $212.00 $425.00 $261.00 $293.00 $633.00 $1,443.00 $1,693.00 $1,968.00 $1,364.00 $1,588.00 $2,151.00 $1,027.00 $2,250.00 $1,409.00 $891.00 $992.00 $1,264.00 $376.00 $937.00 $843.00 $889.00 $891.00 $321.00 $410.00 $136.00 $311.00 $382.00 $490.00 $828.00 $1,203.00 $176.00 -------$259.00 $275.00 $681.00 $982.00 $824.00 $1,096.00 $696.00 $922.00 $626.00 $1,128.00 $1,486.00 $2,167.00 $1,664.00 $2,318.00 $1,619.00 $1,564.00 $1,462.00

$171.00 $225.00 $454.00 $278.00 $312.00 $672.00 $1,532.00 $1,796.00 $2,088.00 $1,455.00 $1,685.00 $2,279.00 $1,085.00 $2,392.00 $1,494.00 $946.00 $1,053.00 $1,338.00 $402.00 $997.00 $896.00 $945.00 $945.00 $342.00 $437.00 $144.00 $331.00 $407.00 $523.00 $877.00 $1,275.00 $186.00 -------$276.00 $292.00 $727.00 $1,046.00 $874.00 $1,163.00 $740.00 $979.00 $665.00 $1,198.00 $1,575.00 $2,358.00 $1,762.00 $2,525.00 $1,714.00 $1,659.00 $1,552.00

$176.00 $232.00 $464.00 $284.00 $323.00 $699.00 $1,597.00 $1,878.00 $2,189.00 $1,511.00 $1,759.00 $2,391.00 $1,140.00 $2,530.00 $1,568.00 $986.00 $1,099.00 $1,401.00 $410.00 $1,043.00 $936.00 $983.00 $988.00 $349.00 $449.00 $151.00 $340.00 $419.00 $537.00 $920.00 $1,340.00 $194.00 -------$283.00 $302.00 $745.00 $1,084.00 $914.00 $1,221.00 $773.00 $1,022.00 $691.00 $1,257.00 $1,647.00 $2,579.00 $1,846.00 $2,773.00 $1,793.00 $1,750.00 $1,616.00

$86.00 $142.00 $180.00 $150.00 $293.00 $633.00 $1,443.00 $1,693.00 $1,968.00 $1,364.00 $1,588.00 $2,151.00 $1,027.00 $2,250.00 $1,409.00 $891.00 $992.00 $1,264.00 $196.00 $744.00 $647.00 $889.00 $891.00 $193.00 $272.00 $83.00 $119.00 $157.00 $202.00 $828.00 $1,203.00 $176.00 -------$152.00 $275.00 $510.00 $759.00 $824.00 $1,096.00 $696.00 $922.00 $626.00 $1,128.00 $1,486.00 $2,167.00 $1,664.00 $2,318.00 $1,619.00 $1,564.00 $1,462.00

$91.00 $151.00 $191.00 $160.00 $312.00 $672.00 $1,532.00 $1,796.00 $2,088.00 $1,455.00 $1,685.00 $2,279.00 $1,085.00 $2,392.00 $1,494.00 $946.00 $1,053.00 $1,338.00 $208.00 $790.00 $686.00 $945.00 $945.00 $205.00 $289.00 $88.00 $125.00 $166.00 $213.00 $877.00 $1,275.00 $186.00 -------$161.00 $292.00 $542.00 $807.00 $874.00 $1,163.00 $740.00 $979.00 $665.00 $1,198.00 $1,575.00 $2,358.00 $1,762.00 $2,525.00 $1,714.00 $1,659.00 $1,552.00

$95.00 $157.00 $200.00 $165.00 $323.00 $699.00 $1,597.00 $1,878.00 $2,189.00 $1,511.00 $1,759.00 $2,391.00 $1,140.00 $2,530.00 $1,568.00 $986.00 $1,099.00 $1,401.00 $216.00 $836.00 $725.00 $983.00 $988.00 $212.00 $301.00 $94.00 $134.00 $177.00 $227.00 $920.00 $1,340.00 $194.00 -------$168.00 $302.00 $560.00 $844.00 $914.00 $1,221.00 $773.00 $1,022.00 $691.00 $1,257.00 $1,647.00 $2,579.00 $1,846.00 $2,773.00 $1,793.00 $1,750.00 $1,616.00


Part B, 204



90 90 90 90 90 0 0 0 0 0 10 0 0 0 0 0 0 0 0 10 10 10 10 10 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0

$463.00 $716.00 $851.00 $1,683.00 $1,908.00 $122.00 $221.00 $217.00 $266.00 $311.00 $775.00 $224.00 $588.00 $601.00 $292.00 $453.00 $690.00 $339.00 $396.00 $1,462.00 $1,551.00 $1,235.00 $1,346.00 $1,587.00 ---------------------BR $1,295.00 $508.00 $1,630.00 $2,238.00 $1,913.00 $2,478.00 $1,891.00 $1,720.00 $1,782.00 $1,822.00 $2,513.00 $2,937.00 $969.00 $969.00 $116.00 $74.00 $62.00 $145.00 $88.00 $197.00 $182.00 $160.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$799.00 $1,059.00 $1,266.00 $2,714.00 $3,020.00 $294.00 $372.00 $424.00 $368.00 $369.00 $883.00 $236.00 $400.00 $588.00 $290.00 $466.00 $742.00 $340.00 $394.00 $1,693.00 $1,812.00 $1,461.00 $1,585.00 $1,813.00 $2,821.00 $2,879.00 $2,825.00 -------$1,886.00 $983.00 $3,074.00 $3,802.00 $3,251.00 $3,629.00 $3,058.00 $2,889.00 $2,856.00 $3,148.00 $4,236.00 $4,472.00 $1,414.00 $1,207.00 $162.00 $51.00 $117.00 $299.00 $302.00 $292.00 $193.00 $262.00

$845.00 $1,123.00 $1,333.00 $2,874.00 $3,199.00 $313.00 $396.00 $451.00 $391.00 $391.00 $929.00 $249.00 $423.00 $620.00 $306.00 $492.00 $783.00 $359.00 $416.00 $1,793.00 $1,926.00 $1,545.00 $1,675.00 $1,916.00 $3,023.00 $3,084.00 $3,027.00 -------$2,002.00 $1,046.00 $3,255.00 $4,024.00 $3,442.00 $3,845.00 $3,242.00 $3,064.00 $3,027.00 $3,336.00 $4,483.00 $4,734.00 $1,500.00 $1,278.00 $169.00 $54.00 $125.00 $319.00 $321.00 $310.00 $204.00 $277.00

$864.00 $1,173.00 $1,372.00 $3,031.00 $3,384.00 $320.00 $408.00 $466.00 $406.00 $407.00 $968.00 $264.00 $449.00 $660.00 $325.00 $524.00 $834.00 $381.00 $442.00 $1,908.00 $2,063.00 $1,637.00 $1,774.00 $2,032.00 $3,046.00 $3,111.00 $3,050.00 -------$2,098.00 $1,081.00 $3,429.00 $4,249.00 $3,617.00 $4,043.00 $3,401.00 $3,219.00 $3,175.00 $3,502.00 $4,728.00 $4,986.00 $1,567.00 $1,344.00 $180.00 $57.00 $128.00 $330.00 $334.00 $322.00 $216.00 $285.00

$799.00 $1,059.00 $1,266.00 $2,714.00 $3,020.00 $95.00 $199.00 $237.00 $236.00 $247.00 $883.00 $236.00 $400.00 $588.00 $290.00 $466.00 $742.00 $340.00 $394.00 $1,693.00 $1,812.00 $1,461.00 $1,585.00 $1,813.00 $240.00 $288.00 $235.00 -------$1,886.00 $983.00 $3,074.00 $3,802.00 $3,251.00 $3,629.00 $3,058.00 $2,889.00 $2,856.00 $3,148.00 $4,236.00 $4,472.00 $1,414.00 $1,207.00 $162.00 $51.00 $71.00 $178.00 $191.00 $189.00 $193.00 $153.00

$845.00 $1,123.00 $1,333.00 $2,874.00 $3,199.00 $100.00 $211.00 $250.00 $249.00 $261.00 $929.00 $249.00 $423.00 $620.00 $306.00 $492.00 $783.00 $359.00 $416.00 $1,793.00 $1,926.00 $1,545.00 $1,675.00 $1,916.00 $254.00 $305.00 $249.00 -------$2,002.00 $1,046.00 $3,255.00 $4,024.00 $3,442.00 $3,845.00 $3,242.00 $3,064.00 $3,027.00 $3,336.00 $4,483.00 $4,734.00 $1,500.00 $1,278.00 $169.00 $54.00 $75.00 $188.00 $202.00 $200.00 $204.00 $160.00

$864.00 $1,173.00 $1,372.00 $3,031.00 $3,384.00 $106.00 $223.00 $264.00 $264.00 $277.00 $968.00 $264.00 $449.00 $660.00 $325.00 $524.00 $834.00 $381.00 $442.00 $1,908.00 $2,063.00 $1,637.00 $1,774.00 $2,032.00 $269.00 $324.00 $264.00 -------$2,098.00 $1,081.00 $3,429.00 $4,249.00 $3,617.00 $4,043.00 $3,401.00 $3,219.00 $3,175.00 $3,502.00 $4,728.00 $4,986.00 $1,567.00 $1,344.00 $180.00 $57.00 $78.00 $199.00 $214.00 $211.00 $216.00 $168.00


Part B, 205



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 YYY 0 0 0 90 90 0 90 90 0 0 0 0 0 0 ZZZ 0 0 0 0 ZZZ

$234.00 $222.00 $262.00 $202.00 $217.00 $284.00 $311.00 $272.00 $308.00 $357.00 $453.00 --------------$446.00 $509.00 $369.00 $363.00 $128.00 $186.00 $230.00 $264.00 $219.00 $1,213.00 $1,881.00 $1,616.00 $913.00 $1,206.00 $691.00 $773.00 BR $306.00 $343.00 $297.00 $794.00 $614.00 $99.00 $384.00 $736.00 $213.00 $230.00 $225.00 $217.00 $235.00 --------------$269.00 $198.00 $308.00 $252.00 --------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$362.00 $232.00 $287.00 $213.00 $238.00 $292.00 $314.00 $280.00 $311.00 $357.00 $390.00 $536.00 $817.00 $463.00 $508.00 $488.00 $369.00 $162.00 $318.00 $345.00 $398.00 $301.00 $1,758.00 $2,730.00 $2,191.00 $1,458.00 $1,646.00 $1,275.00 $1,099.00 -------$593.00 $333.00 $275.00 $1,035.00 $775.00 $120.00 $653.00 $1,086.00 $260.00 $428.00 $464.00 $440.00 $555.00 $1,263.00 $1,942.00 $585.00 $696.00 $294.00 $339.00 $106.00

$384.00 $245.00 $303.00 $225.00 $252.00 $309.00 $332.00 $296.00 $329.00 $377.00 $412.00 $566.00 $864.00 $489.00 $536.00 $519.00 $390.00 $172.00 $338.00 $367.00 $423.00 $319.00 $1,865.00 $2,895.00 $2,324.00 $1,542.00 $1,744.00 $1,358.00 $1,166.00 -------$631.00 $353.00 $292.00 $1,099.00 $823.00 $128.00 $695.00 $1,154.00 $276.00 $454.00 $491.00 $465.00 $588.00 $1,347.00 $2,079.00 $618.00 $738.00 $309.00 $357.00 $111.00

$400.00 $259.00 $322.00 $238.00 $267.00 $328.00 $352.00 $314.00 $349.00 $401.00 $438.00 $601.00 $921.00 $520.00 $570.00 $543.00 $415.00 $178.00 $349.00 $381.00 $440.00 $332.00 $1,950.00 $3,029.00 $2,447.00 $1,630.00 $1,830.00 $1,407.00 $1,218.00 -------$684.00 $381.00 $317.00 $1,157.00 $858.00 $134.00 $726.00 $1,207.00 $287.00 $467.00 $502.00 $476.00 $601.00 $1,368.00 $2,093.00 $631.00 $753.00 $327.00 $381.00 $114.00

$236.00 $232.00 $287.00 $213.00 $238.00 $292.00 $314.00 $280.00 $311.00 $357.00 $390.00 $536.00 $817.00 $463.00 $508.00 $340.00 $369.00 $111.00 $181.00 $220.00 $253.00 $207.00 $1,758.00 $2,730.00 $2,191.00 $1,458.00 $1,646.00 $1,275.00 $1,099.00 -------$593.00 $333.00 $275.00 $1,035.00 $775.00 $72.00 $653.00 $1,086.00 $188.00 $211.00 $213.00 $215.00 $247.00 $310.00 $143.00 $274.00 $291.00 $294.00 $339.00 $72.00

$249.00 $245.00 $303.00 $225.00 $252.00 $309.00 $332.00 $296.00 $329.00 $377.00 $412.00 $566.00 $864.00 $489.00 $536.00 $360.00 $390.00 $118.00 $191.00 $232.00 $267.00 $218.00 $1,865.00 $2,895.00 $2,324.00 $1,542.00 $1,744.00 $1,358.00 $1,166.00 -------$631.00 $353.00 $292.00 $1,099.00 $823.00 $77.00 $695.00 $1,154.00 $198.00 $221.00 $222.00 $224.00 $258.00 $325.00 $149.00 $285.00 $303.00 $309.00 $357.00 $75.00

$264.00 $259.00 $322.00 $238.00 $267.00 $328.00 $352.00 $314.00 $349.00 $401.00 $438.00 $601.00 $921.00 $520.00 $570.00 $383.00 $415.00 $124.00 $202.00 $246.00 $284.00 $231.00 $1,950.00 $3,029.00 $2,447.00 $1,630.00 $1,830.00 $1,407.00 $1,218.00 -------$684.00 $381.00 $317.00 $1,157.00 $858.00 $82.00 $726.00 $1,207.00 $209.00 $233.00 $232.00 $234.00 $270.00 $343.00 $158.00 $297.00 $317.00 $327.00 $381.00 $78.00


Part B, 206



ZZZ 0 0 0 ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90

--------------$298.00 ---------------------$399.00 $304.00 $208.00 $208.00 $161.00 ---------------------------------------------------------------$138.00 $89.00 $103.00 $199.00 $1,088.00 $1,448.00 $1,648.00 $2,315.00 $1,815.00 $1,973.00 $1,577.00 $1,936.00 $1,320.00 $1,866.00 $628.00 $1,175.00 $458.00 $659.00 $460.00 BR $821.00 $908.00 ---------------------$1,120.00 $1,223.00 $1,077.00 $1,144.00 $1,284.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$131.00 $2,563.00 $493.00 $326.00 $108.00 $373.00 $374.00 $379.00 $258.00 $455.00 $408.00 $324.00 $299.00 $102.00 $117.00 $1,254.00 $1,334.00 $202.00 $306.00 $321.00 $364.00 $75.00 $131.00 $1,700.00 $2,033.00 $2,534.00 $2,092.00 $2,694.00 $2,020.00 $1,897.00 $1,749.00 $2,132.00 $1,602.00 $2,162.00 $1,059.00 $1,236.00 $622.00 $863.00 $637.00 -------$1,071.00 $1,157.00 $1,209.00 $1,208.00 $1,146.00 $1,214.00 $2,195.00 $1,303.00 $1,388.00 $1,497.00

$138.00 $2,743.00 $521.00 $342.00 $112.00 $391.00 $393.00 $396.00 $269.00 $481.00 $431.00 $337.00 $311.00 $107.00 $123.00 $1,335.00 $1,420.00 $214.00 $317.00 $333.00 $385.00 $78.00 $136.00 $1,822.00 $2,164.00 $2,695.00 $2,245.00 $2,889.00 $2,166.00 $1,981.00 $1,859.00 $2,254.00 $1,697.00 $2,315.00 $1,125.00 $1,325.00 $662.00 $916.00 $678.00 -------$1,147.00 $1,240.00 $1,295.00 $1,294.00 $1,228.00 $1,301.00 $2,351.00 $1,396.00 $1,487.00 $1,605.00

$142.00 $2,770.00 $538.00 $363.00 $117.00 $416.00 $416.00 $418.00 $281.00 $493.00 $441.00 $354.00 $325.00 $113.00 $132.00 $1,355.00 $1,442.00 $219.00 $330.00 $346.00 $392.00 $81.00 $143.00 $1,846.00 $2,266.00 $2,801.00 $2,466.00 $3,185.00 $2,386.00 $2,074.00 $2,000.00 $2,404.00 $1,814.00 $2,541.00 $1,175.00 $1,448.00 $690.00 $958.00 $709.00 -------$1,248.00 $1,350.00 $1,419.00 $1,417.00 $1,344.00 $1,425.00 $2,577.00 $1,525.00 $1,627.00 $1,761.00

$93.00 $304.00 $276.00 $326.00 $108.00 $373.00 $374.00 $379.00 $258.00 $235.00 $203.00 $324.00 $299.00 $102.00 $117.00 $342.00 $377.00 $99.00 $306.00 $321.00 $157.00 $75.00 $131.00 $221.00 $2,033.00 $2,534.00 $2,092.00 $2,694.00 $2,020.00 $1,897.00 $1,749.00 $2,132.00 $1,602.00 $2,162.00 $1,059.00 $1,236.00 $478.00 $698.00 $500.00 -------$1,071.00 $1,157.00 $1,209.00 $1,208.00 $1,146.00 $1,214.00 $2,195.00 $1,303.00 $1,388.00 $1,497.00

$96.00 $319.00 $289.00 $342.00 $112.00 $391.00 $393.00 $396.00 $269.00 $245.00 $212.00 $337.00 $311.00 $107.00 $123.00 $356.00 $393.00 $103.00 $317.00 $333.00 $163.00 $78.00 $136.00 $235.00 $2,164.00 $2,695.00 $2,245.00 $2,889.00 $2,166.00 $1,981.00 $1,859.00 $2,254.00 $1,697.00 $2,315.00 $1,125.00 $1,325.00 $506.00 $739.00 $531.00 -------$1,147.00 $1,240.00 $1,295.00 $1,294.00 $1,228.00 $1,301.00 $2,351.00 $1,396.00 $1,487.00 $1,605.00

$101.00 $339.00 $305.00 $363.00 $117.00 $416.00 $416.00 $418.00 $281.00 $256.00 $221.00 $354.00 $325.00 $113.00 $132.00 $373.00 $412.00 $108.00 $330.00 $346.00 $170.00 $81.00 $143.00 $255.00 $2,266.00 $2,801.00 $2,466.00 $3,185.00 $2,386.00 $2,074.00 $2,000.00 $2,404.00 $1,814.00 $2,541.00 $1,175.00 $1,448.00 $535.00 $781.00 $562.00 -------$1,248.00 $1,350.00 $1,419.00 $1,417.00 $1,344.00 $1,425.00 $2,577.00 $1,525.00 $1,627.00 $1,761.00


Part B, 207



90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ ZZZ 90 0 0 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90

$1,267.00 $1,226.00 $1,231.00 $842.00 $1,132.00 $1,024.00 $1,680.00 $1,268.00 $1,221.00 $1,787.00 $129.00 $159.00 $1,837.00 $2,093.00 $2,093.00 $1,622.00 $1,714.00 $1,771.00 $1,974.00 $2,094.00 $1,784.00 $374.00 -----------------------------------$1,308.00 -----------------------------------------------------------------------------$456.00 $663.00 $637.00 ---------------------$957.00 $1,166.00 $1,615.00 $1,144.00 $1,096.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,297.00 $1,507.00 $1,502.00 $1,179.00 $1,699.00 $1,188.00 $2,375.00 $1,492.00 $1,363.00 $2,398.00 $214.00 $623.00 $2,355.00 $4,839.00 $5,344.00 $2,223.00 $2,376.00 $2,165.00 $3,556.00 $3,607.00 $2,216.00 $372.00 $2,723.00 $3,109.00 $1,399.00 $238.00 $238.00 $2,614.00 $1,091.00 $253.00 $268.00 $825.00 $281.00 $405.00 $749.00 $718.00 $342.00 $133.00 $121.00 $465.00 $729.00 $698.00 $465.00 $571.00 $389.00 $995.00 $1,648.00 $2,504.00 $1,591.00 $1,784.00

$2,461.00 $1,614.00 $1,608.00 $1,262.00 $1,819.00 $1,270.00 $2,544.00 $1,598.00 $1,458.00 $2,568.00 $226.00 $664.00 $2,523.00 $5,194.00 $5,721.00 $2,381.00 $2,545.00 $2,320.00 $3,811.00 $3,863.00 $2,376.00 $399.00 $2,918.00 $3,331.00 $1,499.00 $255.00 $255.00 $2,801.00 $1,165.00 $267.00 $284.00 $876.00 $298.00 $429.00 $798.00 $763.00 $366.00 $140.00 $127.00 $497.00 $782.00 $748.00 $498.00 $611.00 $416.00 $1,066.00 $1,766.00 $2,683.00 $1,704.00 $1,914.00

$2,705.00 $1,768.00 $1,757.00 $1,376.00 $1,984.00 $1,379.00 $2,785.00 $1,749.00 $1,592.00 $2,813.00 $232.00 $672.00 $2,770.00 $5,729.00 $6,285.00 $2,614.00 $2,789.00 $2,551.00 $4,203.00 $4,247.00 $2,608.00 $442.00 $3,207.00 $3,663.00 $1,641.00 $283.00 $282.00 $3,078.00 $1,192.00 $288.00 $300.00 $891.00 $305.00 $438.00 $809.00 $776.00 $376.00 $147.00 $134.00 $545.00 $862.00 $824.00 $547.00 $672.00 $455.00 $1,162.00 $1,937.00 $2,948.00 $1,867.00 $2,105.00

$2,297.00 $1,507.00 $1,502.00 $1,179.00 $1,699.00 $1,188.00 $2,375.00 $1,492.00 $1,363.00 $2,398.00 $128.00 $151.00 $2,355.00 $4,839.00 $5,344.00 $2,223.00 $2,376.00 $2,165.00 $3,556.00 $3,607.00 $2,216.00 $372.00 $2,723.00 $3,109.00 $1,399.00 $238.00 $238.00 $2,614.00 $329.00 $253.00 $234.00 $284.00 $131.00 $165.00 $181.00 $226.00 $116.00 $101.00 $92.00 $465.00 $729.00 $698.00 $465.00 $571.00 $389.00 $995.00 $1,648.00 $2,504.00 $1,591.00 $1,784.00

$2,461.00 $1,614.00 $1,608.00 $1,262.00 $1,819.00 $1,270.00 $2,544.00 $1,598.00 $1,458.00 $2,568.00 $133.00 $158.00 $2,523.00 $5,194.00 $5,721.00 $2,381.00 $2,545.00 $2,320.00 $3,811.00 $3,863.00 $2,376.00 $399.00 $2,918.00 $3,331.00 $1,499.00 $255.00 $255.00 $2,801.00 $347.00 $267.00 $248.00 $296.00 $137.00 $171.00 $189.00 $235.00 $123.00 $106.00 $96.00 $497.00 $782.00 $748.00 $498.00 $611.00 $416.00 $1,066.00 $1,766.00 $2,683.00 $1,704.00 $1,914.00

$2,705.00 $1,768.00 $1,757.00 $1,376.00 $1,984.00 $1,379.00 $2,785.00 $1,749.00 $1,592.00 $2,813.00 $139.00 $165.00 $2,770.00 $5,729.00 $6,285.00 $2,614.00 $2,789.00 $2,551.00 $4,203.00 $4,247.00 $2,608.00 $442.00 $3,207.00 $3,663.00 $1,641.00 $283.00 $282.00 $3,078.00 $372.00 $288.00 $263.00 $310.00 $144.00 $179.00 $198.00 $246.00 $133.00 $112.00 $103.00 $545.00 $862.00 $824.00 $547.00 $672.00 $455.00 $1,162.00 $1,937.00 $2,948.00 $1,867.00 $2,105.00


Part B, 208



90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 YYY 0 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90

$1,213.00 $1,222.00 $1,142.00 $1,141.00 $1,165.00 $1,459.00 $1,636.00 $1,197.00 $1,360.00 ----------------------------------------------------------------------$1,166.00 $1,085.00 $1,917.00 $1,848.00 $3,100.00 $3,339.00 $3,787.00 $4,038.00 $1,532.00 $1,661.00 $2,100.00 $1,555.00 $126.00 $312.00 -------BR $124.00 $125.00 $555.00 $1,178.00 $1,165.00 $1,786.00 $1,816.00 $1,224.00 $2,358.00 $1,734.00 $1,571.00 $254.00 --------------$642.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,435.00 $1,204.00 $1,070.00 $1,095.00 $1,203.00 $1,339.00 $2,111.00 $1,279.00 $1,843.00 $1,307.00 $239.00 $238.00 $2,029.00 $2,414.00 $2,673.00 $2,296.00 $1,833.00 $328.00 $329.00 $1,420.00 $1,354.00 $4,219.00 $2,005.00 $4,985.00 $5,458.00 $6,952.00 $7,390.00 $2,104.00 $2,021.00 $2,500.00 $1,859.00 $205.00 $502.00 $3,294.00 -------$181.00 $182.00 $758.00 $1,320.00 $1,199.00 $3,024.00 $3,733.00 $1,498.00 $3,170.00 $2,076.00 $2,377.00 $200.00 $1,167.00 $1,214.00 $689.00

$1,538.00 $1,290.00 $1,147.00 $1,174.00 $1,291.00 $1,435.00 $2,262.00 $1,370.00 $1,973.00 $1,400.00 $256.00 $255.00 $2,175.00 $2,586.00 $2,863.00 $2,461.00 $1,964.00 $352.00 $352.00 $1,523.00 $1,452.00 $4,519.00 $2,149.00 $5,346.00 $5,854.00 $7,453.00 $7,921.00 $2,252.00 $2,167.00 $2,680.00 $1,994.00 $218.00 $521.00 $3,521.00 -------$194.00 $195.00 $809.00 $1,414.00 $1,285.00 $3,240.00 $3,996.00 $1,603.00 $3,395.00 $2,224.00 $2,549.00 $214.00 $1,252.00 $1,302.00 $738.00

$1,685.00 $1,411.00 $1,256.00 $1,282.00 $1,415.00 $1,571.00 $2,486.00 $1,500.00 $2,164.00 $1,532.00 $283.00 $283.00 $2,391.00 $2,844.00 $3,149.00 $2,705.00 $2,154.00 $389.00 $388.00 $1,670.00 $1,591.00 $4,968.00 $2,354.00 $5,897.00 $6,465.00 $8,229.00 $8,743.00 $2,462.00 $2,381.00 $2,950.00 $2,193.00 $231.00 $543.00 $3,550.00 -------$213.00 $215.00 $876.00 $1,548.00 $1,408.00 $3,566.00 $4,397.00 $1,753.00 $3,738.00 $2,440.00 $2,812.00 $237.00 $1,374.00 $1,431.00 $804.00

$1,435.00 $1,204.00 $1,070.00 $1,095.00 $1,203.00 $1,339.00 $2,111.00 $1,279.00 $1,843.00 $1,307.00 $239.00 $238.00 $2,029.00 $2,414.00 $2,673.00 $2,296.00 $1,833.00 $328.00 $329.00 $1,420.00 $1,354.00 $4,219.00 $2,005.00 $4,985.00 $5,458.00 $6,952.00 $7,390.00 $2,104.00 $2,021.00 $2,500.00 $1,859.00 $149.00 $502.00 $417.00 -------$181.00 $182.00 $758.00 $1,320.00 $1,199.00 $3,024.00 $3,733.00 $1,498.00 $3,170.00 $2,076.00 $2,377.00 $200.00 $1,167.00 $1,214.00 $689.00

$1,538.00 $1,290.00 $1,147.00 $1,174.00 $1,291.00 $1,435.00 $2,262.00 $1,370.00 $1,973.00 $1,400.00 $256.00 $255.00 $2,175.00 $2,586.00 $2,863.00 $2,461.00 $1,964.00 $352.00 $352.00 $1,523.00 $1,452.00 $4,519.00 $2,149.00 $5,346.00 $5,854.00 $7,453.00 $7,921.00 $2,252.00 $2,167.00 $2,680.00 $1,994.00 $158.00 $521.00 $434.00 -------$194.00 $195.00 $809.00 $1,414.00 $1,285.00 $3,240.00 $3,996.00 $1,603.00 $3,395.00 $2,224.00 $2,549.00 $214.00 $1,252.00 $1,302.00 $738.00

$1,685.00 $1,411.00 $1,256.00 $1,282.00 $1,415.00 $1,571.00 $2,486.00 $1,500.00 $2,164.00 $1,532.00 $283.00 $283.00 $2,391.00 $2,844.00 $3,149.00 $2,705.00 $2,154.00 $389.00 $388.00 $1,670.00 $1,591.00 $4,968.00 $2,354.00 $5,897.00 $6,465.00 $8,229.00 $8,743.00 $2,462.00 $2,381.00 $2,950.00 $2,193.00 $171.00 $543.00 $455.00 -------$213.00 $215.00 $876.00 $1,548.00 $1,408.00 $3,566.00 $4,397.00 $1,753.00 $3,738.00 $2,440.00 $2,812.00 $237.00 $1,374.00 $1,431.00 $804.00


Part B, 209



90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90

$753.00 $573.00 $204.00 $210.00 $511.00 $437.00 $532.00 $304.00 $402.00 $428.00 $488.00 $390.00 -------$471.00 $585.00 $490.00 $434.00 $472.00 -----------------------------------$270.00 $598.00 $587.00 $933.00 $1,184.00 $1,235.00 $648.00 $301.00 $1,650.00 $1,081.00 $1,271.00 $1,687.00 $2,071.00 ------------------------------------------$1,993.00 --------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$737.00 $798.00 $270.00 $276.00 $498.00 $519.00 $730.00 $462.00 $570.00 $559.00 $596.00 $597.00 $556.00 $517.00 $626.00 $776.00 $705.00 $743.00 $523.00 $545.00 $575.00 $593.00 $617.00 $359.00 $741.00 $965.00 $1,173.00 $1,261.00 $1,396.00 $564.00 $338.00 $2,056.00 $1,299.00 $1,387.00 $2,212.00 $2,446.00 $2,066.00 $2,437.00 $2,951.00 $872.00 $980.00 $1,266.00 $2,473.00 $574.00 $597.00 $622.00 $2,045.00 $2,787.00 $881.00 $741.00

$789.00 $855.00 $289.00 $296.00 $533.00 $556.00 $782.00 $496.00 $610.00 $599.00 $639.00 $640.00 $596.00 $554.00 $671.00 $831.00 $756.00 $796.00 $560.00 $585.00 $616.00 $635.00 $661.00 $384.00 $794.00 $1,034.00 $1,258.00 $1,352.00 $1,494.00 $605.00 $363.00 $2,202.00 $1,392.00 $1,486.00 $2,372.00 $2,619.00 $2,215.00 $2,605.00 $3,164.00 $934.00 $1,048.00 $1,355.00 $2,650.00 $615.00 $640.00 $667.00 $2,189.00 $2,986.00 $945.00 $795.00

$863.00 $935.00 $318.00 $325.00 $581.00 $606.00 $852.00 $541.00 $664.00 $652.00 $695.00 $696.00 $649.00 $601.00 $730.00 $914.00 $832.00 $874.00 $610.00 $637.00 $671.00 $694.00 $721.00 $416.00 $866.00 $1,127.00 $1,376.00 $1,478.00 $1,630.00 $660.00 $393.00 $2,414.00 $1,520.00 $1,625.00 $2,612.00 $2,874.00 $2,434.00 $2,854.00 $3,483.00 $1,020.00 $1,145.00 $1,481.00 $2,913.00 $671.00 $698.00 $728.00 $2,397.00 $3,284.00 $1,030.00 $865.00

$737.00 $798.00 $270.00 $276.00 $498.00 $519.00 $730.00 $462.00 $570.00 $559.00 $596.00 $597.00 $556.00 $517.00 $626.00 $776.00 $705.00 $743.00 $523.00 $545.00 $575.00 $593.00 $617.00 $359.00 $741.00 $965.00 $1,173.00 $1,261.00 $1,396.00 $564.00 $338.00 $2,056.00 $1,299.00 $1,387.00 $2,212.00 $2,446.00 $2,066.00 $2,437.00 $2,951.00 $872.00 $980.00 $1,266.00 $2,473.00 $574.00 $597.00 $622.00 $2,045.00 $2,787.00 $881.00 $741.00

$789.00 $855.00 $289.00 $296.00 $533.00 $556.00 $782.00 $496.00 $610.00 $599.00 $639.00 $640.00 $596.00 $554.00 $671.00 $831.00 $756.00 $796.00 $560.00 $585.00 $616.00 $635.00 $661.00 $384.00 $794.00 $1,034.00 $1,258.00 $1,352.00 $1,494.00 $605.00 $363.00 $2,202.00 $1,392.00 $1,486.00 $2,372.00 $2,619.00 $2,215.00 $2,605.00 $3,164.00 $934.00 $1,048.00 $1,355.00 $2,650.00 $615.00 $640.00 $667.00 $2,189.00 $2,986.00 $945.00 $795.00

$863.00 $935.00 $318.00 $325.00 $581.00 $606.00 $852.00 $541.00 $664.00 $652.00 $695.00 $696.00 $649.00 $601.00 $730.00 $914.00 $832.00 $874.00 $610.00 $637.00 $671.00 $694.00 $721.00 $416.00 $866.00 $1,127.00 $1,376.00 $1,478.00 $1,630.00 $660.00 $393.00 $2,414.00 $1,520.00 $1,625.00 $2,612.00 $2,874.00 $2,434.00 $2,854.00 $3,483.00 $1,020.00 $1,145.00 $1,481.00 $2,913.00 $671.00 $698.00 $728.00 $2,397.00 $3,284.00 $1,030.00 $865.00


Part B, 210



90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90

--------------$470.00 $365.00 $1,576.00 $1,889.00 $1,577.00 $1,875.00 $1,485.00 $1,890.00 $1,935.00 $1,726.00 $2,336.00 ---------------------------------------------------------------$2,401.00 $2,228.00 $2,369.00 $2,698.00 $2,745.00 $2,962.00 $2,637.00 $2,981.00 $3,213.00 $3,282.00 $2,904.00 $2,563.00 $2,684.00 $2,756.00 --------------$1,796.00 $2,431.00 $2,509.00 $2,806.00 $3,026.00 $2,891.00 $2,215.00 $2,396.00 $2,547.00 $2,665.00 $2,952.00 $1,749.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$524.00 $593.00 $354.00 $312.00 $3,706.00 $6,215.00 $1,772.00 $2,887.00 $1,600.00 $1,853.00 $2,094.00 $2,147.00 $2,818.00 $2,057.00 $2,250.00 $2,336.00 $2,451.00 $2,698.00 $2,921.00 $948.00 $1,138.00 $1,504.00 $3,438.00 $2,175.00 $2,235.00 $2,660.00 $3,429.00 $4,350.00 $3,826.00 $5,077.00 $4,814.00 $4,929.00 $3,277.00 $3,052.00 $3,069.00 $2,531.00 $2,702.00 $636.00 $2,203.00 $2,522.00 $4,134.00 $3,597.00 $3,694.00 $4,227.00 $3,700.00 $4,674.00 $3,687.00 $4,168.00 $3,738.00 $1,950.00

$562.00 $627.00 $379.00 $335.00 $3,970.00 $6,657.00 $1,900.00 $3,091.00 $1,714.00 $1,989.00 $2,243.00 $2,298.00 $3,012.00 $2,204.00 $2,411.00 $2,502.00 $2,626.00 $2,892.00 $3,131.00 $1,014.00 $1,220.00 $1,613.00 $3,679.00 $2,333.00 $2,397.00 $2,852.00 $3,671.00 $4,659.00 $4,093.00 $5,435.00 $5,162.00 $5,286.00 $3,516.00 $3,261.00 $3,288.00 $2,715.00 $2,887.00 $678.00 $2,363.00 $2,700.00 $4,427.00 $3,851.00 $3,954.00 $4,526.00 $3,970.00 $5,003.00 $3,945.00 $4,462.00 $4,010.00 $2,092.00

$612.00 $666.00 $411.00 $363.00 $4,375.00 $7,347.00 $2,088.00 $3,400.00 $1,882.00 $2,186.00 $2,463.00 $2,522.00 $3,302.00 $2,431.00 $2,662.00 $2,759.00 $2,899.00 $3,192.00 $3,460.00 $1,118.00 $1,353.00 $1,788.00 $4,044.00 $2,563.00 $2,634.00 $3,142.00 $4,038.00 $5,130.00 $4,497.00 $5,985.00 $5,708.00 $5,840.00 $3,883.00 $3,573.00 $3,617.00 $2,988.00 $3,157.00 $741.00 $2,601.00 $2,963.00 $4,873.00 $4,235.00 $4,352.00 $4,979.00 $4,386.00 $5,508.00 $4,336.00 $4,911.00 $4,431.00 $2,293.00

$524.00 $593.00 $354.00 $312.00 $3,706.00 $6,215.00 $1,772.00 $2,887.00 $1,600.00 $1,853.00 $2,094.00 $2,147.00 $2,818.00 $2,057.00 $2,250.00 $2,336.00 $2,451.00 $2,698.00 $2,921.00 $948.00 $1,138.00 $1,504.00 $3,438.00 $2,175.00 $2,235.00 $2,660.00 $3,429.00 $4,350.00 $3,826.00 $5,077.00 $4,814.00 $4,929.00 $3,277.00 $3,052.00 $3,069.00 $2,531.00 $2,702.00 $636.00 $2,203.00 $2,522.00 $4,134.00 $3,597.00 $3,694.00 $4,227.00 $3,700.00 $4,674.00 $3,687.00 $4,168.00 $3,738.00 $1,950.00

$562.00 $627.00 $379.00 $335.00 $3,970.00 $6,657.00 $1,900.00 $3,091.00 $1,714.00 $1,989.00 $2,243.00 $2,298.00 $3,012.00 $2,204.00 $2,411.00 $2,502.00 $2,626.00 $2,892.00 $3,131.00 $1,014.00 $1,220.00 $1,613.00 $3,679.00 $2,333.00 $2,397.00 $2,852.00 $3,671.00 $4,659.00 $4,093.00 $5,435.00 $5,162.00 $5,286.00 $3,516.00 $3,261.00 $3,288.00 $2,715.00 $2,887.00 $678.00 $2,363.00 $2,700.00 $4,427.00 $3,851.00 $3,954.00 $4,526.00 $3,970.00 $5,003.00 $3,945.00 $4,462.00 $4,010.00 $2,092.00

$612.00 $666.00 $411.00 $363.00 $4,375.00 $7,347.00 $2,088.00 $3,400.00 $1,882.00 $2,186.00 $2,463.00 $2,522.00 $3,302.00 $2,431.00 $2,662.00 $2,759.00 $2,899.00 $3,192.00 $3,460.00 $1,118.00 $1,353.00 $1,788.00 $4,044.00 $2,563.00 $2,634.00 $3,142.00 $4,038.00 $5,130.00 $4,497.00 $5,985.00 $5,708.00 $5,840.00 $3,883.00 $3,573.00 $3,617.00 $2,988.00 $3,157.00 $741.00 $2,601.00 $2,963.00 $4,873.00 $4,235.00 $4,352.00 $4,979.00 $4,386.00 $5,508.00 $4,336.00 $4,911.00 $4,431.00 $2,293.00


Part B, 211



90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,929.00 $2,173.00 $2,666.00 $2,270.00 -------$2,544.00 $2,595.00 $2,370.00 $1,546.00 $1,938.00 $1,983.00 $2,416.00 $2,423.00 $2,448.00 -------$17.00 $2,354.00 $2,546.00 $2,732.00 $2,933.00 $3,197.00 $3,404.00 $219.00 $414.00 $607.00 $801.00 $994.00 $1,189.00 $521.00 $2,415.00 $2,654.00 $2,899.00 $3,143.00 $2,693.00 $3,250.00 -------$340.00 $2,644.00 $2,556.00 $2,831.00 $2,940.00 $2,871.00 $2,985.00 $3,152.00 $3,051.00 $3,272.00 $3,678.00 ----------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,084.00 $3,316.00 $3,519.00 $2,309.00 $1,925.00 $2,387.00 $2,524.00 $2,359.00 $1,709.00 $1,933.00 $2,008.00 $2,223.00 $3,150.00 $3,134.00 $2,627.00 $24.00 $2,917.00 $3,206.00 $3,647.00 $3,753.00 $3,949.00 $4,133.00 $285.00 $625.00 $827.00 $992.00 $1,112.00 $1,265.00 $800.00 $2,821.00 $3,320.00 $3,703.00 $3,993.00 $3,973.00 $4,694.00 $4,476.00 $350.00 $2,610.00 $2,533.00 $2,816.00 $2,735.00 $2,697.00 $3,114.00 $3,054.00 $3,038.00 $3,293.00 $4,146.00 $2,514.00 $1,413.00 $5,510.00

$2,236.00 $3,557.00 $3,767.00 $2,477.00 $2,031.00 $2,560.00 $2,705.00 $2,523.00 $1,833.00 $2,073.00 $2,154.00 $2,385.00 $3,379.00 $3,362.00 $2,818.00 $26.00 $3,122.00 $3,433.00 $3,904.00 $4,018.00 $4,225.00 $4,432.00 $305.00 $669.00 $885.00 $1,061.00 $1,191.00 $1,353.00 $856.00 $3,020.00 $3,555.00 $3,964.00 $4,273.00 $4,254.00 $5,030.00 $4,791.00 $375.00 $2,800.00 $2,717.00 $3,021.00 $2,934.00 $2,894.00 $3,341.00 $3,276.00 $3,259.00 $3,533.00 $4,448.00 $2,696.00 $1,516.00 $5,911.00

$2,450.00 $3,925.00 $4,143.00 $2,725.00 $2,179.00 $2,817.00 $2,977.00 $2,763.00 $2,015.00 $2,277.00 $2,364.00 $2,622.00 $3,737.00 $3,715.00 $3,111.00 $29.00 $3,432.00 $3,774.00 $4,295.00 $4,421.00 $4,646.00 $4,893.00 $337.00 $740.00 $978.00 $1,173.00 $1,315.00 $1,494.00 $947.00 $3,319.00 $3,909.00 $4,360.00 $4,699.00 $4,685.00 $5,550.00 $5,271.00 $414.00 $3,082.00 $2,991.00 $3,316.00 $3,232.00 $3,187.00 $3,673.00 $3,617.00 $3,594.00 $3,898.00 $4,903.00 $2,976.00 $1,667.00 $6,508.00

$2,084.00 $3,316.00 $3,519.00 $2,309.00 $1,925.00 $2,387.00 $2,524.00 $2,359.00 $1,709.00 $1,933.00 $2,008.00 $2,223.00 $3,150.00 $3,134.00 $2,627.00 $24.00 $2,917.00 $3,206.00 $3,647.00 $3,753.00 $3,949.00 $4,133.00 $285.00 $625.00 $827.00 $992.00 $1,112.00 $1,265.00 $800.00 $2,821.00 $3,320.00 $3,703.00 $3,993.00 $3,973.00 $4,694.00 $4,476.00 $350.00 $2,610.00 $2,533.00 $2,816.00 $2,735.00 $2,697.00 $3,114.00 $3,054.00 $3,038.00 $3,293.00 $4,146.00 $2,514.00 $1,413.00 $5,510.00

$2,236.00 $3,557.00 $3,767.00 $2,477.00 $2,031.00 $2,560.00 $2,705.00 $2,523.00 $1,833.00 $2,073.00 $2,154.00 $2,385.00 $3,379.00 $3,362.00 $2,818.00 $26.00 $3,122.00 $3,433.00 $3,904.00 $4,018.00 $4,225.00 $4,432.00 $305.00 $669.00 $885.00 $1,061.00 $1,191.00 $1,353.00 $856.00 $3,020.00 $3,555.00 $3,964.00 $4,273.00 $4,254.00 $5,030.00 $4,791.00 $375.00 $2,800.00 $2,717.00 $3,021.00 $2,934.00 $2,894.00 $3,341.00 $3,276.00 $3,259.00 $3,533.00 $4,448.00 $2,696.00 $1,516.00 $5,911.00

$2,450.00 $3,925.00 $4,143.00 $2,725.00 $2,179.00 $2,817.00 $2,977.00 $2,763.00 $2,015.00 $2,277.00 $2,364.00 $2,622.00 $3,737.00 $3,715.00 $3,111.00 $29.00 $3,432.00 $3,774.00 $4,295.00 $4,421.00 $4,646.00 $4,893.00 $337.00 $740.00 $978.00 $1,173.00 $1,315.00 $1,494.00 $947.00 $3,319.00 $3,909.00 $4,360.00 $4,699.00 $4,685.00 $5,550.00 $5,271.00 $414.00 $3,082.00 $2,991.00 $3,316.00 $3,232.00 $3,187.00 $3,673.00 $3,617.00 $3,594.00 $3,898.00 $4,903.00 $2,976.00 $1,667.00 $6,508.00


Part B, 212



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,981.00 $2,352.00 $2,732.00 $2,444.00 $2,700.00 $2,820.00 ---------------------$2,657.00 $2,740.00 $2,602.00 $1,884.00 $2,816.00 $2,856.00 $3,064.00 $2,549.00 $2,731.00 $2,508.00 $2,704.00 --------------$2,785.00 $2,622.00 $2,036.00 $2,288.00 $1,977.00 $1,877.00 $1,831.00 $1,900.00 $1,895.00 $2,119.00 $2,173.00 -------$2,954.00 $2,924.00 $2,681.00 $2,654.00 $2,844.00 $2,724.00 $3,199.00 $3,121.00 $3,232.00 $3,057.00 --------------$2,970.00 $2,288.00 $1,546.00 $1,752.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,496.00 $2,635.00 $2,770.00 $2,676.00 $2,917.00 $3,012.00 $3,006.00 $3,232.00 $3,359.00 $2,793.00 $3,014.00 $2,875.00 $1,816.00 $3,134.00 $3,114.00 $3,134.00 $2,348.00 $3,277.00 $2,349.00 $2,474.00 $2,342.00 $3,100.00 $3,052.00 $2,502.00 $1,963.00 $2,132.00 $2,043.00 $1,916.00 $1,995.00 $2,027.00 $1,995.00 $2,024.00 $2,161.00 $638.00 $3,390.00 $3,497.00 $2,734.00 $2,939.00 $3,105.00 $3,011.00 $3,746.00 $3,731.00 $3,616.00 $3,715.00 $4,930.00 $5,602.00 $3,470.00 $2,433.00 $1,499.00 $1,641.00

$2,677.00 $2,826.00 $2,971.00 $2,871.00 $3,129.00 $3,231.00 $3,225.00 $3,467.00 $3,603.00 $2,996.00 $3,233.00 $3,084.00 $1,948.00 $3,362.00 $3,341.00 $3,362.00 $2,519.00 $3,515.00 $2,520.00 $2,653.00 $2,513.00 $3,325.00 $3,274.00 $2,684.00 $2,106.00 $2,287.00 $2,192.00 $2,056.00 $2,140.00 $2,174.00 $2,140.00 $2,171.00 $2,318.00 $684.00 $3,637.00 $3,752.00 $2,932.00 $3,153.00 $3,331.00 $3,230.00 $4,019.00 $4,002.00 $3,878.00 $3,985.00 $5,289.00 $6,009.00 $3,723.00 $2,610.00 $1,608.00 $1,760.00

$2,953.00 $3,118.00 $3,279.00 $3,168.00 $3,454.00 $3,573.00 $3,560.00 $3,813.00 $3,962.00 $3,298.00 $3,554.00 $3,409.00 $2,138.00 $3,700.00 $3,673.00 $3,712.00 $2,773.00 $3,866.00 $2,774.00 $2,926.00 $2,770.00 $3,671.00 $3,612.00 $2,955.00 $2,313.00 $2,514.00 $2,402.00 $2,263.00 $2,351.00 $2,386.00 $2,351.00 $2,390.00 $2,554.00 $759.00 $4,002.00 $4,131.00 $3,229.00 $3,462.00 $3,656.00 $3,549.00 $4,418.00 $4,406.00 $4,288.00 $4,388.00 $5,849.00 $6,616.00 $4,113.00 $2,866.00 $1,769.00 $1,931.00

$2,496.00 $2,635.00 $2,770.00 $2,676.00 $2,917.00 $3,012.00 $3,006.00 $3,232.00 $3,359.00 $2,793.00 $3,014.00 $2,875.00 $1,816.00 $3,134.00 $3,114.00 $3,134.00 $2,348.00 $3,277.00 $2,349.00 $2,474.00 $2,342.00 $3,100.00 $3,052.00 $2,502.00 $1,963.00 $2,132.00 $2,043.00 $1,916.00 $1,995.00 $2,027.00 $1,995.00 $2,024.00 $2,161.00 $638.00 $3,390.00 $3,497.00 $2,734.00 $2,939.00 $3,105.00 $3,011.00 $3,746.00 $3,731.00 $3,616.00 $3,715.00 $4,930.00 $5,602.00 $3,470.00 $2,433.00 $1,499.00 $1,641.00

$2,677.00 $2,826.00 $2,971.00 $2,871.00 $3,129.00 $3,231.00 $3,225.00 $3,467.00 $3,603.00 $2,996.00 $3,233.00 $3,084.00 $1,948.00 $3,362.00 $3,341.00 $3,362.00 $2,519.00 $3,515.00 $2,520.00 $2,653.00 $2,513.00 $3,325.00 $3,274.00 $2,684.00 $2,106.00 $2,287.00 $2,192.00 $2,056.00 $2,140.00 $2,174.00 $2,140.00 $2,171.00 $2,318.00 $684.00 $3,637.00 $3,752.00 $2,932.00 $3,153.00 $3,331.00 $3,230.00 $4,019.00 $4,002.00 $3,878.00 $3,985.00 $5,289.00 $6,009.00 $3,723.00 $2,610.00 $1,608.00 $1,760.00

$2,953.00 $3,118.00 $3,279.00 $3,168.00 $3,454.00 $3,573.00 $3,560.00 $3,813.00 $3,962.00 $3,298.00 $3,554.00 $3,409.00 $2,138.00 $3,700.00 $3,673.00 $3,712.00 $2,773.00 $3,866.00 $2,774.00 $2,926.00 $2,770.00 $3,671.00 $3,612.00 $2,955.00 $2,313.00 $2,514.00 $2,402.00 $2,263.00 $2,351.00 $2,386.00 $2,351.00 $2,390.00 $2,554.00 $759.00 $4,002.00 $4,131.00 $3,229.00 $3,462.00 $3,656.00 $3,549.00 $4,418.00 $4,406.00 $4,288.00 $4,388.00 $5,849.00 $6,616.00 $4,113.00 $2,866.00 $1,769.00 $1,931.00


Part B, 213



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 0 0 90 90 90 90 90 90 ZZZ 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$1,746.00 $1,935.00 $2,464.00 $1,619.00 $1,559.00 $1,884.00 $2,029.00 $2,129.00 $2,129.00 $2,311.00 $3,057.00 $3,044.00 $3,183.00 -------$3,638.00 $2,876.00 $3,767.00 -------------------------------------------------$1,987.00 $1,588.00 $2,096.00 $2,345.00 $2,981.00 $2,227.00 $421.00 --------------$5,415.00 $3,813.00 ----------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,747.00 $1,949.00 $2,312.00 $1,469.00 $1,609.00 $1,787.00 $1,878.00 $2,021.00 $1,928.00 $2,122.00 $2,785.00 $4,863.00 $4,773.00 $4,883.00 $3,807.00 $4,167.00 $5,543.00 $2,755.00 $2,366.00 $1,709.00 $628.00 $1,476.00 $1,214.00 $1,498.00 $3,977.00 $1,934.00 $6,395.00 $2,210.00 $2,882.00 $2,108.00 $438.00 $2,617.00 $3,873.00 $7,565.00 $7,361.00 $461.00 $509.00 $363.00 $353.00 $623.00 $653.00 $696.00 $730.00 $1,245.00 $1,274.00 $276.00 $273.00 $351.00 $361.00 $702.00

$1,874.00 $2,091.00 $2,480.00 $1,576.00 $1,726.00 $1,916.00 $2,014.00 $2,168.00 $2,069.00 $2,276.00 $2,988.00 $5,207.00 $5,110.00 $5,230.00 $4,076.00 $4,464.00 $5,939.00 $2,948.00 $2,532.00 $1,827.00 $672.00 $1,578.00 $1,300.00 $1,605.00 $4,258.00 $2,068.00 $6,860.00 $2,370.00 $3,091.00 $2,261.00 $469.00 $2,808.00 $4,155.00 $8,095.00 $7,887.00 $489.00 $541.00 $384.00 $374.00 $658.00 $700.00 $734.00 $783.00 $1,310.00 $1,364.00 $291.00 $288.00 $369.00 $386.00 $739.00

$2,063.00 $2,290.00 $2,728.00 $1,732.00 $1,891.00 $2,105.00 $2,213.00 $2,383.00 $2,274.00 $2,504.00 $3,291.00 $5,737.00 $5,635.00 $5,770.00 $4,486.00 $4,921.00 $6,564.00 $3,251.00 $2,791.00 $2,007.00 $743.00 $1,736.00 $1,442.00 $1,786.00 $4,686.00 $2,282.00 $7,587.00 $2,606.00 $3,397.00 $2,487.00 $521.00 $3,099.00 $4,572.00 $8,898.00 $8,698.00 $533.00 $590.00 $417.00 $406.00 $706.00 $774.00 $788.00 $866.00 $1,396.00 $1,508.00 $310.00 $309.00 $393.00 $424.00 $787.00

$1,747.00 $1,949.00 $2,312.00 $1,469.00 $1,609.00 $1,787.00 $1,878.00 $2,021.00 $1,928.00 $2,122.00 $2,785.00 $4,863.00 $4,773.00 $4,883.00 $3,807.00 $4,167.00 $5,543.00 $2,755.00 $2,366.00 $1,709.00 $628.00 $1,476.00 $1,214.00 $1,498.00 $3,977.00 $1,934.00 $6,395.00 $2,210.00 $2,882.00 $2,108.00 $438.00 $2,617.00 $3,873.00 $7,565.00 $7,361.00 $461.00 $509.00 $363.00 $353.00 $623.00 $653.00 $696.00 $730.00 $1,245.00 $1,274.00 $276.00 $273.00 $351.00 $361.00 $702.00

$1,874.00 $2,091.00 $2,480.00 $1,576.00 $1,726.00 $1,916.00 $2,014.00 $2,168.00 $2,069.00 $2,276.00 $2,988.00 $5,207.00 $5,110.00 $5,230.00 $4,076.00 $4,464.00 $5,939.00 $2,948.00 $2,532.00 $1,827.00 $672.00 $1,578.00 $1,300.00 $1,605.00 $4,258.00 $2,068.00 $6,860.00 $2,370.00 $3,091.00 $2,261.00 $469.00 $2,808.00 $4,155.00 $8,095.00 $7,887.00 $489.00 $541.00 $384.00 $374.00 $658.00 $700.00 $734.00 $783.00 $1,310.00 $1,364.00 $291.00 $288.00 $369.00 $386.00 $739.00

$2,063.00 $2,290.00 $2,728.00 $1,732.00 $1,891.00 $2,105.00 $2,213.00 $2,383.00 $2,274.00 $2,504.00 $3,291.00 $5,737.00 $5,635.00 $5,770.00 $4,486.00 $4,921.00 $6,564.00 $3,251.00 $2,791.00 $2,007.00 $743.00 $1,736.00 $1,442.00 $1,786.00 $4,686.00 $2,282.00 $7,587.00 $2,606.00 $3,397.00 $2,487.00 $521.00 $3,099.00 $4,572.00 $8,898.00 $8,698.00 $533.00 $590.00 $417.00 $406.00 $706.00 $774.00 $788.00 $866.00 $1,396.00 $1,508.00 $310.00 $309.00 $393.00 $424.00 $787.00


Part B, 214



0 0 0 0 0 0 0 90 0 90 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 0 0 0 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

---------------------$258.00 $51.00 -------$576.00 $578.00 $756.00 $1,095.00 $1,758.00 $2,056.00 $1,561.00 $1,754.00 $2,496.00 $3,212.00 -------------------------------------------------------------------------------------------BR $1,012.00 $1,134.00 $800.00 $669.00 $1,288.00 $777.00 $949.00 $953.00 $779.00 $1,117.00 $685.00 $660.00 $910.00 $2,044.00 $1,108.00 $1,077.00 $1,368.00 $1,159.00 $1,279.00 --------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$734.00 $276.00 $357.00 $393.00 $51.00 $409.00 $539.00 $1,067.00 $781.00 $1,334.00 $2,002.00 $2,440.00 $1,715.00 $2,030.00 $2,976.00 $2,717.00 $1,275.00 $3,013.00 $3,530.00 $434.00 $771.00 $803.00 $317.00 $1,181.00 $762.00 $667.00 $972.00 $315.00 $277.00 -------$1,491.00 $1,496.00 $923.00 $919.00 $2,152.00 $1,587.00 $1,470.00 $2,207.00 $1,119.00 $2,224.00 $1,666.00 $933.00 $1,489.00 $2,333.00 $1,807.00 $1,543.00 $1,654.00 $1,737.00 $1,915.00 $1,980.00

$774.00 $291.00 $382.00 $421.00 $54.00 $430.00 $577.00 $1,142.00 $835.00 $1,428.00 $2,144.00 $2,615.00 $1,837.00 $2,174.00 $3,189.00 $2,912.00 $1,367.00 $3,224.00 $3,781.00 $464.00 $812.00 $858.00 $339.00 $1,264.00 $815.00 $716.00 $1,042.00 $338.00 $296.00 -------$1,597.00 $1,605.00 $989.00 $985.00 $2,305.00 $1,700.00 $1,575.00 $2,359.00 $1,197.00 $2,378.00 $1,785.00 $1,000.00 $1,597.00 $2,494.00 $1,940.00 $1,653.00 $1,771.00 $1,859.00 $2,049.00 $2,118.00

$829.00 $310.00 $421.00 $465.00 $59.00 $458.00 $637.00 $1,248.00 $921.00 $1,559.00 $2,369.00 $2,892.00 $2,027.00 $2,399.00 $3,529.00 $3,217.00 $1,516.00 $3,559.00 $4,182.00 $512.00 $865.00 $943.00 $374.00 $1,395.00 $897.00 $791.00 $1,151.00 $373.00 $327.00 -------$1,759.00 $1,762.00 $1,088.00 $1,083.00 $2,543.00 $1,876.00 $1,736.00 $2,583.00 $1,315.00 $2,626.00 $1,976.00 $1,099.00 $1,753.00 $2,736.00 $2,130.00 $1,824.00 $1,931.00 $2,048.00 $2,256.00 $2,334.00

$734.00 $276.00 $357.00 $393.00 $51.00 $409.00 $539.00 $1,067.00 $781.00 $1,334.00 $2,002.00 $2,440.00 $1,715.00 $2,030.00 $2,976.00 $2,717.00 $1,275.00 $3,013.00 $3,530.00 $434.00 $771.00 $803.00 $317.00 $1,181.00 $762.00 $667.00 $972.00 $315.00 $277.00 -------$1,491.00 $1,496.00 $923.00 $919.00 $2,152.00 $1,587.00 $1,470.00 $2,207.00 $1,119.00 $2,224.00 $1,666.00 $933.00 $1,489.00 $2,333.00 $1,807.00 $1,543.00 $1,654.00 $1,737.00 $1,915.00 $1,980.00

$774.00 $291.00 $382.00 $421.00 $54.00 $430.00 $577.00 $1,142.00 $835.00 $1,428.00 $2,144.00 $2,615.00 $1,837.00 $2,174.00 $3,189.00 $2,912.00 $1,367.00 $3,224.00 $3,781.00 $464.00 $812.00 $858.00 $339.00 $1,264.00 $815.00 $716.00 $1,042.00 $338.00 $296.00 -------$1,597.00 $1,605.00 $989.00 $985.00 $2,305.00 $1,700.00 $1,575.00 $2,359.00 $1,197.00 $2,378.00 $1,785.00 $1,000.00 $1,597.00 $2,494.00 $1,940.00 $1,653.00 $1,771.00 $1,859.00 $2,049.00 $2,118.00

$829.00 $310.00 $421.00 $465.00 $59.00 $458.00 $637.00 $1,248.00 $921.00 $1,559.00 $2,369.00 $2,892.00 $2,027.00 $2,399.00 $3,529.00 $3,217.00 $1,516.00 $3,559.00 $4,182.00 $512.00 $865.00 $943.00 $374.00 $1,395.00 $897.00 $791.00 $1,151.00 $373.00 $327.00 -------$1,759.00 $1,762.00 $1,088.00 $1,083.00 $2,543.00 $1,876.00 $1,736.00 $2,583.00 $1,315.00 $2,626.00 $1,976.00 $1,099.00 $1,753.00 $2,736.00 $2,130.00 $1,824.00 $1,931.00 $2,048.00 $2,256.00 $2,334.00


Part B, 215



90 90 ZZZ ZZZ 0 ZZZ 0 90 ZZZ 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,279.00 --------------$220.00 $359.00 $256.00 $519.00 $694.00 $220.00 $1,803.00 $1,950.00 $1,950.00 $650.00 $306.00 $960.00 $1,564.00 $1,547.00 $1,268.00 $1,007.00 $1,376.00 $1,635.00 $1,686.00 $995.00 $2,175.00 $2,661.00 $2,634.00 $2,872.00 $2,346.00 $2,587.00 $1,398.00 $1,351.00 $2,000.00 $2,382.00 $1,495.00 $1,742.00 $1,231.00 $1,339.00 $1,390.00 $1,229.00 $997.00 $1,345.00 $976.00 $1,048.00 $1,380.00 $1,018.00 $852.00 $835.00 $935.00 $1,833.00 $1,494.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,914.00 $1,836.00 $155.00 $320.00 $521.00 $366.00 $759.00 $1,064.00 $317.00 $2,722.00 $2,939.00 $2,912.00 $939.00 $420.00 $1,375.00 $1,721.00 $1,754.00 $1,639.00 $1,541.00 $1,926.00 $1,907.00 $2,111.00 $1,520.00 $2,693.00 $3,384.00 $2,772.00 $4,010.00 $2,917.00 $3,467.00 $2,326.00 $2,803.00 $2,533.00 $3,274.00 $2,138.00 $2,518.00 $1,704.00 $2,038.00 $1,915.00 $2,163.00 $1,392.00 $2,715.00 $1,599.00 $1,719.00 $2,361.00 $1,163.00 $1,447.00 $1,184.00 $1,109.00 $2,086.00 $3,107.00

$2,048.00 $1,967.00 $166.00 $343.00 $558.00 $392.00 $813.00 $1,138.00 $339.00 $2,912.00 $3,150.00 $3,112.00 $1,006.00 $450.00 $1,472.00 $1,843.00 $1,879.00 $1,743.00 $1,652.00 $2,064.00 $2,045.00 $2,248.00 $1,628.00 $2,885.00 $3,626.00 $2,969.00 $4,294.00 $3,126.00 $3,714.00 $2,495.00 $3,001.00 $2,714.00 $3,510.00 $2,290.00 $2,694.00 $1,826.00 $2,183.00 $2,051.00 $2,317.00 $1,479.00 $2,912.00 $1,716.00 $1,826.00 $2,528.00 $1,247.00 $1,549.00 $1,267.00 $1,179.00 $2,233.00 $3,329.00

$2,256.00 $2,173.00 $184.00 $382.00 $619.00 $436.00 $901.00 $1,247.00 $375.00 $3,219.00 $3,494.00 $3,437.00 $1,114.00 $498.00 $1,619.00 $2,031.00 $2,080.00 $1,886.00 $1,822.00 $2,275.00 $2,251.00 $2,444.00 $1,788.00 $3,188.00 $4,008.00 $3,289.00 $4,749.00 $3,456.00 $4,109.00 $2,742.00 $3,289.00 $3,000.00 $3,857.00 $2,527.00 $2,979.00 $2,015.00 $2,409.00 $2,265.00 $2,566.00 $1,582.00 $3,209.00 $1,891.00 $1,949.00 $2,793.00 $1,370.00 $1,697.00 $1,390.00 $1,257.00 $2,451.00 $3,660.00

$1,914.00 $1,836.00 $155.00 $320.00 $521.00 $366.00 $759.00 $1,064.00 $317.00 $2,722.00 $2,939.00 $2,912.00 $939.00 $420.00 $1,375.00 $1,721.00 $1,754.00 $1,639.00 $1,541.00 $1,926.00 $1,907.00 $2,111.00 $1,520.00 $2,693.00 $3,384.00 $2,772.00 $4,010.00 $2,917.00 $3,467.00 $2,326.00 $2,803.00 $2,533.00 $3,274.00 $2,138.00 $2,518.00 $1,704.00 $2,038.00 $1,915.00 $2,163.00 $1,392.00 $2,715.00 $1,599.00 $1,719.00 $2,361.00 $1,163.00 $1,447.00 $1,184.00 $1,109.00 $2,086.00 $3,107.00

$2,048.00 $1,967.00 $166.00 $343.00 $558.00 $392.00 $813.00 $1,138.00 $339.00 $2,912.00 $3,150.00 $3,112.00 $1,006.00 $450.00 $1,472.00 $1,843.00 $1,879.00 $1,743.00 $1,652.00 $2,064.00 $2,045.00 $2,248.00 $1,628.00 $2,885.00 $3,626.00 $2,969.00 $4,294.00 $3,126.00 $3,714.00 $2,495.00 $3,001.00 $2,714.00 $3,510.00 $2,290.00 $2,694.00 $1,826.00 $2,183.00 $2,051.00 $2,317.00 $1,479.00 $2,912.00 $1,716.00 $1,826.00 $2,528.00 $1,247.00 $1,549.00 $1,267.00 $1,179.00 $2,233.00 $3,329.00

$2,256.00 $2,173.00 $184.00 $382.00 $619.00 $436.00 $901.00 $1,247.00 $375.00 $3,219.00 $3,494.00 $3,437.00 $1,114.00 $498.00 $1,619.00 $2,031.00 $2,080.00 $1,886.00 $1,822.00 $2,275.00 $2,251.00 $2,444.00 $1,788.00 $3,188.00 $4,008.00 $3,289.00 $4,749.00 $3,456.00 $4,109.00 $2,742.00 $3,289.00 $3,000.00 $3,857.00 $2,527.00 $2,979.00 $2,015.00 $2,409.00 $2,265.00 $2,566.00 $1,582.00 $3,209.00 $1,891.00 $1,949.00 $2,793.00 $1,370.00 $1,697.00 $1,390.00 $1,257.00 $2,451.00 $3,660.00


Part B, 216



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 0 0 0 0 0 0 0 0 ZZZ 90 90 90 90 90 90 90 90 90

$1,243.00 $841.00 $1,053.00 $947.00 $1,926.00 $1,701.00 $1,260.00 $1,568.00 $1,008.00 $921.00 $1,814.00 $1,541.00 $1,396.00 $1,036.00 $1,486.00 -----------------------------------$1,999.00 $1,031.00 $1,724.00 $1,908.00 $1,555.00 $1,336.00 $1,859.00 $2,006.00 $1,006.00 $1,085.00 $225.00 $224.00 $643.00 $518.00 $804.00 $430.00 $626.00 $388.00 $569.00 $338.00 $423.00 $1,569.00 $1,641.00 $1,564.00 $1,529.00 -------$1,256.00 -------$1,387.00 $1,391.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,221.00 $1,277.00 $1,832.00 $1,500.00 $2,066.00 $2,389.00 $2,605.00 $1,565.00 $1,622.00 $1,336.00 $2,076.00 $2,209.00 $2,481.00 $1,436.00 $1,742.00 $1,734.00 $1,919.00 $1,980.00 $1,896.00 $708.00 $2,249.00 $1,369.00 $2,234.00 $2,107.00 $1,975.00 $1,598.00 $2,375.00 $2,689.00 $1,262.00 $1,513.00 $246.00 $231.00 $781.00 $527.00 $759.00 $483.00 $3,562.00 $2,565.00 $2,168.00 $1,983.00 $493.00 $2,304.00 $1,973.00 $2,096.00 $2,180.00 $1,904.00 $1,734.00 $1,886.00 $2,157.00 $1,889.00

$2,380.00 $1,368.00 $1,950.00 $1,604.00 $2,187.00 $2,558.00 $2,792.00 $1,676.00 $1,739.00 $1,431.00 $2,220.00 $2,369.00 $2,659.00 $1,539.00 $1,867.00 $1,857.00 $2,056.00 $2,120.00 $2,030.00 $759.00 $2,411.00 $1,467.00 $2,392.00 $2,257.00 $2,115.00 $1,712.00 $2,544.00 $2,883.00 $1,352.00 $1,621.00 $263.00 $247.00 $837.00 $564.00 $814.00 $518.00 $3,816.00 $2,749.00 $2,316.00 $2,120.00 $528.00 $2,467.00 $2,114.00 $2,250.00 $2,333.00 $2,040.00 $1,858.00 $2,021.00 $2,273.00 $2,024.00

$2,622.00 $1,506.00 $2,107.00 $1,762.00 $2,351.00 $2,810.00 $3,081.00 $1,846.00 $1,915.00 $1,576.00 $2,432.00 $2,608.00 $2,932.00 $1,694.00 $2,060.00 $2,049.00 $2,268.00 $2,340.00 $2,241.00 $842.00 $2,672.00 $1,618.00 $2,641.00 $2,492.00 $2,337.00 $1,891.00 $2,817.00 $3,182.00 $1,490.00 $1,788.00 $292.00 $275.00 $928.00 $624.00 $901.00 $572.00 $3,904.00 $2,813.00 $2,357.00 $2,152.00 $586.00 $2,727.00 $2,343.00 $2,496.00 $2,581.00 $2,261.00 $2,060.00 $2,238.00 $2,414.00 $2,243.00

$2,221.00 $1,277.00 $1,832.00 $1,500.00 $2,066.00 $2,389.00 $2,605.00 $1,565.00 $1,622.00 $1,336.00 $2,076.00 $2,209.00 $2,481.00 $1,436.00 $1,742.00 $1,734.00 $1,919.00 $1,980.00 $1,896.00 $708.00 $2,249.00 $1,369.00 $2,234.00 $2,107.00 $1,975.00 $1,598.00 $2,375.00 $2,689.00 $1,262.00 $1,513.00 $246.00 $231.00 $781.00 $527.00 $759.00 $483.00 $794.00 $542.00 $499.00 $402.00 $493.00 $2,304.00 $1,973.00 $2,096.00 $2,180.00 $1,904.00 $1,734.00 $1,886.00 $2,157.00 $1,889.00

$2,380.00 $1,368.00 $1,950.00 $1,604.00 $2,187.00 $2,558.00 $2,792.00 $1,676.00 $1,739.00 $1,431.00 $2,220.00 $2,369.00 $2,659.00 $1,539.00 $1,867.00 $1,857.00 $2,056.00 $2,120.00 $2,030.00 $759.00 $2,411.00 $1,467.00 $2,392.00 $2,257.00 $2,115.00 $1,712.00 $2,544.00 $2,883.00 $1,352.00 $1,621.00 $263.00 $247.00 $837.00 $564.00 $814.00 $518.00 $847.00 $579.00 $525.00 $423.00 $528.00 $2,467.00 $2,114.00 $2,250.00 $2,333.00 $2,040.00 $1,858.00 $2,021.00 $2,273.00 $2,024.00

$2,622.00 $1,506.00 $2,107.00 $1,762.00 $2,351.00 $2,810.00 $3,081.00 $1,846.00 $1,915.00 $1,576.00 $2,432.00 $2,608.00 $2,932.00 $1,694.00 $2,060.00 $2,049.00 $2,268.00 $2,340.00 $2,241.00 $842.00 $2,672.00 $1,618.00 $2,641.00 $2,492.00 $2,337.00 $1,891.00 $2,817.00 $3,182.00 $1,490.00 $1,788.00 $292.00 $275.00 $928.00 $624.00 $901.00 $572.00 $926.00 $636.00 $561.00 $451.00 $586.00 $2,727.00 $2,343.00 $2,496.00 $2,581.00 $2,261.00 $2,060.00 $2,238.00 $2,414.00 $2,243.00


Part B, 217



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,313.00 $1,393.00 ---------------------$1,527.00 $2,000.00 $1,716.00 -------$1,888.00 ----------------------------$1,745.00 $1,219.00 $1,899.00 $1,115.00 $1,312.00 $2,161.00 -------$1,612.00 $369.00 $1,843.00 $2,277.00 $1,698.00 $273.00 $1,495.00 $1,539.00 $1,349.00 $1,346.00 $1,265.00 $1,193.00 $1,921.00 $1,891.00 ---------------------$1,656.00 --------------$1,298.00 $1,304.00 $2,105.00 $1,555.00 $1,236.00 $1,603.00 $1,589.00 $1,145.00 $1,237.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,793.00 $1,910.00 $1,863.00 $1,972.00 $1,762.00 $2,605.00 $3,120.00 $2,313.00 $2,965.00 $2,617.00 $3,382.00 $3,630.00 $3,391.00 $3,799.00 $2,162.00 $1,898.00 $2,654.00 $2,053.00 $2,043.00 $2,584.00 $2,349.00 $2,055.00 $534.00 $2,235.00 $2,596.00 $2,108.00 $388.00 $2,166.00 $1,812.00 $1,656.00 $1,707.00 $1,697.00 $2,034.00 $2,414.00 $2,860.00 $2,790.00 $3,096.00 $2,734.00 $2,481.00 $2,661.00 $2,721.00 $1,522.00 $1,563.00 $2,651.00 $2,403.00 $1,663.00 $2,116.00 $1,674.00 $1,673.00 $1,935.00

$1,922.00 $2,046.00 $1,995.00 $2,111.00 $1,886.00 $2,789.00 $3,341.00 $2,474.00 $3,178.00 $2,804.00 $3,626.00 $3,886.00 $3,627.00 $4,070.00 $2,316.00 $2,032.00 $2,841.00 $2,196.00 $2,188.00 $2,767.00 $2,517.00 $2,201.00 $572.00 $2,394.00 $2,781.00 $2,257.00 $415.00 $2,320.00 $1,940.00 $1,775.00 $1,829.00 $1,818.00 $2,179.00 $2,586.00 $3,064.00 $2,987.00 $3,315.00 $2,927.00 $2,659.00 $2,849.00 $2,915.00 $1,631.00 $1,676.00 $2,839.00 $2,575.00 $1,781.00 $2,267.00 $1,793.00 $1,792.00 $2,071.00

$2,129.00 $2,266.00 $2,201.00 $2,323.00 $2,079.00 $3,069.00 $3,692.00 $2,735.00 $3,524.00 $3,109.00 $4,013.00 $4,303.00 $4,011.00 $4,514.00 $2,556.00 $2,238.00 $3,143.00 $2,424.00 $2,415.00 $3,058.00 $2,782.00 $2,431.00 $634.00 $2,643.00 $3,074.00 $2,490.00 $457.00 $2,562.00 $2,142.00 $1,961.00 $2,027.00 $2,007.00 $2,414.00 $2,849.00 $3,389.00 $3,307.00 $3,664.00 $3,242.00 $2,949.00 $3,143.00 $3,220.00 $1,803.00 $1,846.00 $3,135.00 $2,844.00 $1,962.00 $2,503.00 $1,977.00 $1,976.00 $2,281.00

$1,793.00 $1,910.00 $1,863.00 $1,972.00 $1,762.00 $2,605.00 $3,120.00 $2,313.00 $2,965.00 $2,617.00 $3,382.00 $3,630.00 $3,391.00 $3,799.00 $2,162.00 $1,898.00 $2,654.00 $2,053.00 $2,043.00 $2,584.00 $2,349.00 $2,055.00 $534.00 $2,235.00 $2,596.00 $2,108.00 $388.00 $2,166.00 $1,812.00 $1,656.00 $1,707.00 $1,697.00 $2,034.00 $2,414.00 $2,860.00 $2,790.00 $3,096.00 $2,734.00 $2,481.00 $2,661.00 $2,721.00 $1,522.00 $1,563.00 $2,651.00 $2,403.00 $1,663.00 $2,116.00 $1,674.00 $1,673.00 $1,935.00

$1,922.00 $2,046.00 $1,995.00 $2,111.00 $1,886.00 $2,789.00 $3,341.00 $2,474.00 $3,178.00 $2,804.00 $3,626.00 $3,886.00 $3,627.00 $4,070.00 $2,316.00 $2,032.00 $2,841.00 $2,196.00 $2,188.00 $2,767.00 $2,517.00 $2,201.00 $572.00 $2,394.00 $2,781.00 $2,257.00 $415.00 $2,320.00 $1,940.00 $1,775.00 $1,829.00 $1,818.00 $2,179.00 $2,586.00 $3,064.00 $2,987.00 $3,315.00 $2,927.00 $2,659.00 $2,849.00 $2,915.00 $1,631.00 $1,676.00 $2,839.00 $2,575.00 $1,781.00 $2,267.00 $1,793.00 $1,792.00 $2,071.00

$2,129.00 $2,266.00 $2,201.00 $2,323.00 $2,079.00 $3,069.00 $3,692.00 $2,735.00 $3,524.00 $3,109.00 $4,013.00 $4,303.00 $4,011.00 $4,514.00 $2,556.00 $2,238.00 $3,143.00 $2,424.00 $2,415.00 $3,058.00 $2,782.00 $2,431.00 $634.00 $2,643.00 $3,074.00 $2,490.00 $457.00 $2,562.00 $2,142.00 $1,961.00 $2,027.00 $2,007.00 $2,414.00 $2,849.00 $3,389.00 $3,307.00 $3,664.00 $3,242.00 $2,949.00 $3,143.00 $3,220.00 $1,803.00 $1,846.00 $3,135.00 $2,844.00 $1,962.00 $2,503.00 $1,977.00 $1,976.00 $2,281.00


Part B, 218



90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0

$1,333.00 $1,686.00 $1,315.00 $751.00 $627.00 $702.00 $216.00 $178.00 $1,546.00 $1,140.00 $1,353.00 $1,351.00 -------$264.00 $494.00 $500.00 $499.00 $532.00 $567.00 $951.00 $771.00 $496.00 $1,583.00 $827.00 $1,232.00 $1,163.00 $1,275.00 --------------$709.00 $818.00 $1,343.00 $1,335.00 $46.00 $181.00 $68.00 $136.00 $194.00 $186.00 $141.00 $159.00 $186.00 $176.00 $120.00 $106.00 --------------$196.00 $240.00 $240.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,810.00 $1,954.00 $1,721.00 $124.00 $547.00 $639.00 $308.00 $251.00 $1,478.00 $1,248.00 $1,528.00 $1,618.00 $229.00 $237.00 $851.00 $695.00 $784.00 $586.00 $1,075.00 $3,044.00 $1,797.00 $1,289.00 $1,921.00 $914.00 $1,456.00 $1,423.00 $1,574.00 $1,867.00 $1,916.00 $724.00 $863.00 $2,604.00 $2,956.00 $36.00 $232.00 $449.00 $700.00 $1,158.00 $1,197.00 $1,087.00 $1,124.00 $1,205.00 $704.00 $591.00 $612.00 $1,167.00 $364.00 $687.00 $873.00 $1,564.00

$1,938.00 $2,093.00 $1,843.00 $132.00 $586.00 $685.00 $330.00 $269.00 $1,581.00 $1,329.00 $1,637.00 $1,733.00 $245.00 $254.00 $906.00 $744.00 $840.00 $627.00 $1,147.00 $3,259.00 $1,924.00 $1,380.00 $2,057.00 $980.00 $1,560.00 $1,524.00 $1,686.00 $1,999.00 $2,052.00 $776.00 $925.00 $2,789.00 $3,167.00 $38.00 $246.00 $480.00 $748.00 $1,238.00 $1,279.00 $1,163.00 $1,201.00 $1,286.00 $754.00 $633.00 $655.00 $1,246.00 $389.00 $733.00 $935.00 $1,672.00

$2,137.00 $2,306.00 $2,028.00 $146.00 $650.00 $761.00 $366.00 $299.00 $1,743.00 $1,450.00 $1,812.00 $1,912.00 $272.00 $281.00 $975.00 $814.00 $916.00 $677.00 $1,244.00 $3,587.00 $2,109.00 $1,518.00 $2,275.00 $1,078.00 $1,720.00 $1,680.00 $1,860.00 $2,208.00 $2,272.00 $851.00 $1,012.00 $3,088.00 $3,505.00 $39.00 $257.00 $487.00 $766.00 $1,259.00 $1,301.00 $1,178.00 $1,219.00 $1,303.00 $779.00 $649.00 $672.00 $1,269.00 $395.00 $746.00 $962.00 $1,703.00

$1,810.00 $1,954.00 $1,721.00 $124.00 $547.00 $639.00 $308.00 $251.00 $1,478.00 $1,248.00 $1,528.00 $1,618.00 $229.00 $237.00 $851.00 $695.00 $784.00 $586.00 $1,075.00 $3,044.00 $1,797.00 $1,289.00 $1,921.00 $914.00 $1,456.00 $1,423.00 $1,574.00 $1,867.00 $1,916.00 $724.00 $863.00 $2,604.00 $2,956.00 $14.00 $158.00 $72.00 $184.00 $235.00 $260.00 $187.00 $223.00 $254.00 $235.00 $152.00 $156.00 $278.00 $73.00 $183.00 $233.00 $351.00

$1,938.00 $2,093.00 $1,843.00 $132.00 $586.00 $685.00 $330.00 $269.00 $1,581.00 $1,329.00 $1,637.00 $1,733.00 $245.00 $254.00 $906.00 $744.00 $840.00 $627.00 $1,147.00 $3,259.00 $1,924.00 $1,380.00 $2,057.00 $980.00 $1,560.00 $1,524.00 $1,686.00 $1,999.00 $2,052.00 $776.00 $925.00 $2,789.00 $3,167.00 $14.00 $167.00 $77.00 $194.00 $248.00 $274.00 $196.00 $234.00 $266.00 $250.00 $161.00 $166.00 $293.00 $77.00 $192.00 $249.00 $371.00

$2,137.00 $2,306.00 $2,028.00 $146.00 $650.00 $761.00 $366.00 $299.00 $1,743.00 $1,450.00 $1,812.00 $1,912.00 $272.00 $281.00 $975.00 $814.00 $916.00 $677.00 $1,244.00 $3,587.00 $2,109.00 $1,518.00 $2,275.00 $1,078.00 $1,720.00 $1,680.00 $1,860.00 $2,208.00 $2,272.00 $851.00 $1,012.00 $3,088.00 $3,505.00 $15.00 $178.00 $82.00 $210.00 $266.00 $294.00 $209.00 $249.00 $280.00 $273.00 $175.00 $182.00 $313.00 $82.00 $203.00 $274.00 $398.00


Part B, 219



0 0 ZZZ 0 0 0 0 0 0 ZZZ ZZZ 0 0 0 ZZZ 0 0 0 0 90 90 90 YYY 0 0 0 0 0 0 0 10 10 0 ZZZ 0 ZZZ 0 0 0 0 0 0 0 0 0 0 10 10 10 10

$270.00 $325.00 $79.00 --------------------------------------------------------$249.00 $272.00 $323.00 $53.00 ----------------------------$749.00 $388.00 $297.00 BR $18.00 BR BR $86.00 $37.00 $141.00 NC $76.00 $96.00 ----------------------------$499.00 $159.00 $92.00 $92.00 $92.00 $92.00 $92.00 $92.00 $305.00 ------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,665.00 $2,726.00 $270.00 $1,529.00 $1,837.00 $2,146.00 $2,527.00 $2,097.00 $2,564.00 $358.00 $1,694.00 $1,904.00 $1,252.00 $2,198.00 $214.00 $1,984.00 $2,162.00 $3,141.00 $3,071.00 $939.00 $594.00 $452.00 -------$24.00 --------------$59.00 $48.00 $189.00 BR $211.00 $249.00 $2,138.00 $425.00 $1,684.00 $439.00 $2,819.00 $272.00 $135.00 $136.00 $143.00 $744.00 $2,834.00 $2,855.00 $1,920.00 $331.00 $1,096.00 $1,644.00 $1,863.00 $1,373.00

$1,782.00 $2,920.00 $288.00 $1,638.00 $1,969.00 $2,300.00 $2,709.00 $2,247.00 $2,750.00 $384.00 $1,816.00 $2,037.00 $1,340.00 $2,352.00 $228.00 $2,126.00 $2,318.00 $3,357.00 $3,292.00 $1,008.00 $637.00 $485.00 -------$25.00 --------------$62.00 $51.00 $202.00 BR $226.00 $265.00 $2,291.00 $455.00 $1,804.00 $470.00 $3,010.00 $288.00 $140.00 $141.00 $151.00 $794.00 $3,037.00 $3,063.00 $2,055.00 $350.00 $1,168.00 $1,758.00 $1,998.00 $1,472.00

$1,827.00 $2,975.00 $296.00 $1,676.00 $2,019.00 $2,355.00 $2,773.00 $2,300.00 $2,815.00 $402.00 $1,858.00 $2,075.00 $1,382.00 $2,401.00 $233.00 $2,173.00 $2,384.00 $3,402.00 $3,370.00 $1,101.00 $691.00 $524.00 -------$26.00 --------------$66.00 $52.00 $221.00 BR $234.00 $278.00 $2,340.00 $477.00 $1,849.00 $491.00 $3,043.00 $311.00 $145.00 $146.00 $160.00 $803.00 $3,054.00 $3,084.00 $2,066.00 $362.00 $1,196.00 $1,804.00 $2,059.00 $1,527.00

$416.00 $494.00 $80.00 $326.00 $447.00 $488.00 $544.00 $480.00 $546.00 $172.00 $352.00 $380.00 $407.00 $479.00 $74.00 $425.00 $569.00 $562.00 $660.00 $939.00 $594.00 $452.00 -------$14.00 --------------$59.00 $48.00 $189.00 BR $122.00 $149.00 $425.00 $207.00 $422.00 $206.00 $514.00 $272.00 $135.00 $136.00 $143.00 $135.00 $129.00 $105.00 $146.00 $178.00 $408.00 $526.00 $573.00 $526.00

$443.00 $526.00 $85.00 $348.00 $477.00 $521.00 $582.00 $512.00 $585.00 $184.00 $377.00 $403.00 $433.00 $508.00 $77.00 $453.00 $608.00 $589.00 $706.00 $1,008.00 $637.00 $485.00 -------$14.00 --------------$62.00 $51.00 $202.00 BR $130.00 $158.00 $454.00 $221.00 $449.00 $219.00 $536.00 $288.00 $140.00 $141.00 $151.00 $142.00 $136.00 $112.00 $153.00 $186.00 $430.00 $559.00 $614.00 $563.00

$483.00 $573.00 $92.00 $382.00 $523.00 $571.00 $640.00 $560.00 $643.00 $202.00 $414.00 $436.00 $473.00 $552.00 $82.00 $495.00 $669.00 $626.00 $776.00 $1,101.00 $691.00 $524.00 -------$15.00 --------------$66.00 $52.00 $221.00 BR $138.00 $170.00 $497.00 $243.00 $490.00 $240.00 $562.00 $311.00 $145.00 $146.00 $160.00 $148.00 $144.00 $124.00 $158.00 $198.00 $457.00 $600.00 $671.00 $615.00


Part B, 220



10 0 10 0 10 10 0 10 10 10 0 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 0

---------------------------------------------------------------------------------------------------------------------------------------------------$24.00 $64.00 $133.00 $130.00 $72.00 $159.00 $345.00 $236.00 -------$977.00 $800.00 $721.00 $1,461.00 $867.00 $967.00 $488.00 $810.00 $780.00 $542.00 -------$166.00 $224.00 $1,755.00 $1,666.00 $1,741.00 $1,681.00 $1,769.00 $1,923.00 $914.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$7,501.00 $350.00 $1,818.00 $232.00 $552.00 $731.00 $300.00 $1,070.00 $1,538.00 $1,909.00 $285.00 $1,603.00 $238.00 $422.00 $32.00 $36.00 $43.00 $818.00 $186.00 $179.00 $154.00 $44.00 $75.00 $156.00 $172.00 $87.00 $184.00 $324.00 $222.00 $1,063.00 $1,124.00 $1,120.00 $1,018.00 $2,026.00 $1,226.00 $1,025.00 $946.00 $1,161.00 $1,246.00 $742.00 $1,761.00 $293.00 $200.00 $2,541.00 $3,465.00 $3,243.00 $3,331.00 $3,044.00 $3,508.00 $1,227.00

$8,044.00 $371.00 $1,947.00 $247.00 $590.00 $779.00 $320.00 $1,141.00 $1,645.00 $2,048.00 $303.00 $1,714.00 $252.00 $450.00 $34.00 $39.00 $46.00 $870.00 $198.00 $190.00 $164.00 $47.00 $78.00 $165.00 $179.00 $92.00 $194.00 $344.00 $237.00 $1,139.00 $1,205.00 $1,201.00 $1,091.00 $2,170.00 $1,314.00 $1,098.00 $1,014.00 $1,245.00 $1,335.00 $797.00 $1,887.00 $309.00 $214.00 $2,717.00 $3,718.00 $3,482.00 $3,577.00 $3,237.00 $3,767.00 $1,277.00

$8,117.00 $378.00 $1,992.00 $251.00 $615.00 $802.00 $326.00 $1,160.00 $1,684.00 $2,103.00 $308.00 $1,748.00 $265.00 $475.00 $35.00 $39.00 $47.00 $887.00 $203.00 $195.00 $167.00 $48.00 $82.00 $178.00 $185.00 $99.00 $209.00 $372.00 $261.00 $1,251.00 $1,326.00 $1,320.00 $1,199.00 $2,377.00 $1,443.00 $1,207.00 $1,115.00 $1,367.00 $1,467.00 $868.00 $2,083.00 $317.00 $235.00 $2,750.00 $4,093.00 $3,836.00 $3,939.00 $3,505.00 $4,150.00 $1,336.00

$575.00 $134.00 $481.00 $52.00 $294.00 $319.00 $99.00 $289.00 $455.00 $508.00 $97.00 $421.00 $202.00 $304.00 $32.00 $36.00 $43.00 $272.00 $66.00 $90.00 $54.00 $23.00 $75.00 $156.00 $172.00 $87.00 $184.00 $324.00 $222.00 $1,063.00 $1,124.00 $1,120.00 $1,018.00 $2,026.00 $1,226.00 $1,025.00 $946.00 $1,161.00 $1,246.00 $742.00 $1,761.00 $161.00 $200.00 $442.00 $3,465.00 $3,243.00 $3,331.00 $3,044.00 $3,508.00 $1,227.00

$613.00 $140.00 $512.00 $55.00 $313.00 $338.00 $103.00 $303.00 $483.00 $545.00 $102.00 $446.00 $214.00 $323.00 $34.00 $39.00 $46.00 $284.00 $69.00 $94.00 $57.00 $24.00 $78.00 $165.00 $179.00 $92.00 $194.00 $344.00 $237.00 $1,139.00 $1,205.00 $1,201.00 $1,091.00 $2,170.00 $1,314.00 $1,098.00 $1,014.00 $1,245.00 $1,335.00 $797.00 $1,887.00 $168.00 $214.00 $466.00 $3,718.00 $3,482.00 $3,577.00 $3,237.00 $3,767.00 $1,277.00

$665.00 $146.00 $553.00 $58.00 $338.00 $359.00 $109.00 $320.00 $519.00 $595.00 $106.00 $476.00 $227.00 $348.00 $35.00 $39.00 $47.00 $300.00 $73.00 $99.00 $59.00 $25.00 $82.00 $178.00 $185.00 $99.00 $209.00 $372.00 $261.00 $1,251.00 $1,326.00 $1,320.00 $1,199.00 $2,377.00 $1,443.00 $1,207.00 $1,115.00 $1,367.00 $1,467.00 $868.00 $2,083.00 $174.00 $235.00 $492.00 $4,093.00 $3,836.00 $3,939.00 $3,505.00 $4,150.00 $1,336.00


Part B, 221



0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ ZZZ 0 ZZZ 0 ZZZ 0 0 0 0 ZZZ ZZZ 90 YYY 90 90 90

$425.00 --------------------------------------------------------$302.00 -------$232.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$739.00 BR $364.00 $414.00 $521.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$8,140.00 $3,175.00 $1,011.00 $1,921.00 $2,872.00 $2,466.00 $3,633.00 $2,165.00 $2,231.00 -------$2,118.00 $324.00 $603.00 $529.00 $370.00 $203.00 $1,526.00 $1,670.00 $1,242.00 $4,383.00 $6,450.00 $1,240.00 $3,579.00 $5,311.00 $15,183.00 $12,490.00 $20,496.00 $7,538.00 $14,980.00 $11,469.00 $18,418.00 $1,687.00 $2,049.00 $5,353.00 $5,648.00 $5,694.00 $3,400.00 $5,790.00 $2,803.00 $6,595.00 $10,565.00 $13,409.00 $9,365.00 $1,927.00 $307.00 $1,144.00 -------$1,083.00 $1,067.00 $1,214.00

$8,715.00 $3,402.00 $1,084.00 $2,058.00 $3,072.00 $2,637.00 $3,891.00 $2,316.00 $2,383.00 -------$2,265.00 $337.00 $639.00 $560.00 $390.00 $214.00 $1,634.00 $1,786.00 $1,324.00 $4,699.00 $6,915.00 $1,329.00 $3,839.00 $5,694.00 $16,286.00 $13,396.00 $21,985.00 $8,082.00 $16,067.00 $12,301.00 $19,756.00 $1,809.00 $2,196.00 $5,741.00 $6,056.00 $6,099.00 $3,646.00 $6,204.00 $3,005.00 $7,064.00 $11,317.00 $14,361.00 $10,019.00 $2,067.00 $329.00 $1,228.00 -------$1,153.00 $1,138.00 $1,301.00

$8,766.00 $3,479.00 $1,113.00 $2,102.00 $3,131.00 $2,676.00 $3,928.00 $2,370.00 $2,429.00 -------$2,309.00 $353.00 $692.00 $605.00 $418.00 $230.00 $1,797.00 $1,961.00 $1,443.00 $4,779.00 $7,016.00 $1,364.00 $3,884.00 $5,780.00 $16,433.00 $13,521.00 $22,169.00 $8,194.00 $16,229.00 $12,451.00 $19,936.00 $1,846.00 $2,255.00 $5,804.00 $6,135.00 $6,176.00 $3,688.00 $6,259.00 $3,036.00 $7,137.00 $11,397.00 $14,448.00 $10,102.00 $2,088.00 $342.00 $1,338.00 -------$1,242.00 $1,236.00 $1,430.00

$579.00 $698.00 $256.00 $379.00 $613.00 $438.00 $357.00 $554.00 $548.00 -------$475.00 $324.00 $603.00 $529.00 $370.00 $203.00 $1,526.00 $1,670.00 $1,242.00 $635.00 $780.00 $287.00 $329.00 $698.00 $948.00 $822.00 $1,141.00 $854.00 $1,106.00 $1,089.00 $1,184.00 $310.00 $506.00 $435.00 $618.00 $686.00 $325.00 $473.00 $228.00 $678.00 $737.00 $865.00 $1,014.00 $141.00 $113.00 $1,144.00 -------$1,083.00 $1,067.00 $1,214.00

$603.00 $744.00 $273.00 $404.00 $648.00 $462.00 $376.00 $587.00 $577.00 -------$502.00 $337.00 $639.00 $560.00 $390.00 $214.00 $1,634.00 $1,786.00 $1,324.00 $678.00 $833.00 $307.00 $351.00 $744.00 $1,014.00 $878.00 $1,219.00 $911.00 $1,181.00 $1,164.00 $1,265.00 $331.00 $540.00 $465.00 $659.00 $726.00 $347.00 $500.00 $242.00 $716.00 $773.00 $903.00 $1,059.00 $150.00 $121.00 $1,228.00 -------$1,153.00 $1,138.00 $1,301.00

$631.00 $813.00 $300.00 $443.00 $700.00 $494.00 $403.00 $637.00 $617.00 -------$541.00 $353.00 $692.00 $605.00 $418.00 $230.00 $1,797.00 $1,961.00 $1,443.00 $746.00 $915.00 $338.00 $387.00 $816.00 $1,116.00 $966.00 $1,342.00 $1,001.00 $1,300.00 $1,281.00 $1,392.00 $364.00 $594.00 $513.00 $722.00 $787.00 $380.00 $538.00 $265.00 $771.00 $822.00 $950.00 $1,116.00 $166.00 $134.00 $1,338.00 -------$1,242.00 $1,236.00 $1,430.00


Part B, 222



90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 10 90 90 90 90 90 10 0 10 90

$563.00 $456.00 $278.00 $495.00 $1,128.00 $1,132.00 $514.00 -------$430.00 $789.00 $336.00 --------------$847.00 $813.00 ---------------------$301.00 $270.00 $1,654.00 $690.00 BR $974.00 $982.00 $332.00 $1,020.00 $1,138.00 BR $180.00 $79.00 $79.00 $212.00 $228.00 $265.00 -------$128.00 $128.00 $90.00 -------$104.00 $375.00 $425.00 $628.00 $1,087.00 $798.00 $234.00 $139.00 $349.00 $431.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$868.00 $571.00 $447.00 $752.00 $1,661.00 $2,021.00 $577.00 $2,487.00 $770.00 $1,776.00 $376.00 $662.00 $730.00 $1,039.00 $938.00 $836.00 $953.00 $1,136.00 $384.00 $519.00 $1,890.00 $736.00 -------$1,732.00 $1,735.00 $396.00 $1,898.00 $1,576.00 -------$172.00 $119.00 $120.00 $230.00 $233.00 $290.00 $289.00 $322.00 $241.00 $169.00 $169.00 $394.00 $703.00 $662.00 $831.00 $1,202.00 $921.00 $481.00 $178.00 $757.00 $687.00

$931.00 $612.00 $478.00 $797.00 $1,780.00 $2,162.00 $617.00 $2,662.00 $825.00 $1,904.00 $403.00 $710.00 $783.00 $1,115.00 $1,005.00 $895.00 $1,019.00 $1,214.00 $411.00 $556.00 $1,986.00 $778.00 -------$1,857.00 $1,858.00 $424.00 $2,029.00 $1,691.00 -------$178.00 $124.00 $125.00 $245.00 $247.00 $305.00 $304.00 $335.00 $251.00 $176.00 $175.00 $421.00 $753.00 $710.00 $880.00 $1,289.00 $984.00 $516.00 $189.00 $808.00 $734.00

$1,010.00 $668.00 $503.00 $844.00 $1,952.00 $2,370.00 $670.00 $2,929.00 $902.00 $2,107.00 $437.00 $776.00 $858.00 $1,218.00 $1,103.00 $977.00 $1,082.00 $1,293.00 $447.00 $592.00 $2,100.00 $825.00 -------$2,036.00 $2,032.00 $466.00 $2,217.00 $1,849.00 -------$187.00 $128.00 $129.00 $251.00 $251.00 $323.00 $321.00 $345.00 $258.00 $181.00 $180.00 $440.00 $814.00 $771.00 $929.00 $1,410.00 $1,073.00 $551.00 $194.00 $860.00 $793.00

$868.00 $571.00 $307.00 $752.00 $1,661.00 $2,021.00 $577.00 $2,487.00 $770.00 $1,776.00 $376.00 $662.00 $730.00 $1,039.00 $938.00 $836.00 $679.00 $831.00 $384.00 $394.00 $1,890.00 $736.00 -------$1,732.00 $1,735.00 $396.00 $1,898.00 $1,576.00 -------$172.00 $119.00 $120.00 $90.00 $108.00 $290.00 $289.00 $322.00 $241.00 $169.00 $169.00 $270.00 $703.00 $662.00 $831.00 $1,202.00 $921.00 $377.00 $103.00 $623.00 $687.00

$931.00 $612.00 $328.00 $797.00 $1,780.00 $2,162.00 $617.00 $2,662.00 $825.00 $1,904.00 $403.00 $710.00 $783.00 $1,115.00 $1,005.00 $895.00 $725.00 $887.00 $411.00 $422.00 $1,986.00 $778.00 -------$1,857.00 $1,858.00 $424.00 $2,029.00 $1,691.00 -------$178.00 $124.00 $125.00 $95.00 $112.00 $305.00 $304.00 $335.00 $251.00 $176.00 $175.00 $288.00 $753.00 $710.00 $880.00 $1,289.00 $984.00 $404.00 $108.00 $664.00 $734.00

$1,010.00 $668.00 $353.00 $844.00 $1,952.00 $2,370.00 $670.00 $2,929.00 $902.00 $2,107.00 $437.00 $776.00 $858.00 $1,218.00 $1,103.00 $977.00 $788.00 $965.00 $447.00 $457.00 $2,100.00 $825.00 -------$2,036.00 $2,032.00 $466.00 $2,217.00 $1,849.00 -------$187.00 $128.00 $129.00 $100.00 $116.00 $323.00 $321.00 $345.00 $258.00 $181.00 $180.00 $306.00 $814.00 $771.00 $929.00 $1,410.00 $1,073.00 $439.00 $113.00 $716.00 $793.00


Part B, 223



90 90 90 90 90 90 90 10 10 10 YYY 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 0 0 90 ZZZ YYY 90 90 90 90 0 0 YYY 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90

$369.00 $517.00 $507.00 $519.00 $1,115.00 $799.00 $831.00 $695.00 $902.00 $1,049.00 BR $863.00 $1,328.00 $1,366.00 $539.00 $770.00 $312.00 $337.00 $699.00 $1,283.00 $1,111.00 $1,357.00 $158.00 $26.00 $298.00 -------BR $664.00 $1,148.00 $1,249.00 $1,542.00 --------------BR $1,083.00 $2,726.00 $1,133.00 $1,179.00 $1,102.00 $968.00 $1,328.00 BR $108.00 $422.00 $469.00 $467.00 $714.00 $851.00 $501.00 $368.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$648.00 $813.00 $762.00 $749.00 $1,496.00 $1,036.00 $1,047.00 $742.00 $978.00 $1,380.00 -------$1,184.00 $1,986.00 $2,141.00 $1,034.00 $1,307.00 $327.00 $403.00 $1,252.00 $1,924.00 $1,187.00 $1,506.00 $122.00 $58.00 $433.00 $209.00 -------$739.00 $1,181.00 $1,325.00 $1,708.00 $469.00 $614.00 -------$1,267.00 $9,268.00 $1,296.00 $1,415.00 $1,339.00 $1,190.00 $1,850.00 -------$183.00 $723.00 $696.00 $703.00 $807.00 $906.00 $776.00 $629.00

$696.00 $870.00 $810.00 $803.00 $1,605.00 $1,104.00 $1,120.00 $787.00 $1,029.00 $1,470.00 -------$1,253.00 $2,107.00 $2,266.00 $1,109.00 $1,401.00 $350.00 $432.00 $1,340.00 $2,054.00 $1,254.00 $1,593.00 $130.00 $61.00 $454.00 $224.00 -------$791.00 $1,265.00 $1,420.00 $1,827.00 $503.00 $658.00 -------$1,357.00 $9,948.00 $1,388.00 $1,517.00 $1,434.00 $1,274.00 $1,982.00 -------$194.00 $770.00 $741.00 $748.00 $857.00 $959.00 $826.00 $670.00

$757.00 $940.00 $865.00 $870.00 $1,751.00 $1,189.00 $1,219.00 $844.00 $1,091.00 $1,591.00 -------$1,331.00 $2,253.00 $2,411.00 $1,209.00 $1,530.00 $387.00 $477.00 $1,457.00 $2,235.00 $1,338.00 $1,701.00 $138.00 $64.00 $470.00 $247.00 -------$857.00 $1,384.00 $1,557.00 $1,998.00 $554.00 $726.00 -------$1,480.00 $10,980.00 $1,517.00 $1,661.00 $1,568.00 $1,390.00 $2,162.00 -------$201.00 $799.00 $772.00 $779.00 $906.00 $1,012.00 $863.00 $694.00

$648.00 $813.00 $762.00 $749.00 $1,496.00 $1,036.00 $1,047.00 $742.00 $978.00 $1,380.00 -------$1,184.00 $1,986.00 $2,141.00 $1,034.00 $1,307.00 $327.00 $403.00 $1,252.00 $1,924.00 $1,187.00 $1,506.00 $122.00 $58.00 $433.00 $209.00 -------$739.00 $1,181.00 $1,325.00 $1,708.00 $469.00 $614.00 -------$1,267.00 $9,268.00 $1,296.00 $1,415.00 $1,339.00 $1,190.00 $1,850.00 -------$107.00 $530.00 $522.00 $525.00 $807.00 $906.00 $591.00 $435.00

$696.00 $870.00 $810.00 $803.00 $1,605.00 $1,104.00 $1,120.00 $787.00 $1,029.00 $1,470.00 -------$1,253.00 $2,107.00 $2,266.00 $1,109.00 $1,401.00 $350.00 $432.00 $1,340.00 $2,054.00 $1,254.00 $1,593.00 $130.00 $61.00 $454.00 $224.00 -------$791.00 $1,265.00 $1,420.00 $1,827.00 $503.00 $658.00 -------$1,357.00 $9,948.00 $1,388.00 $1,517.00 $1,434.00 $1,274.00 $1,982.00 -------$113.00 $563.00 $555.00 $557.00 $857.00 $959.00 $628.00 $462.00

$757.00 $940.00 $865.00 $870.00 $1,751.00 $1,189.00 $1,219.00 $844.00 $1,091.00 $1,591.00 -------$1,331.00 $2,253.00 $2,411.00 $1,209.00 $1,530.00 $387.00 $477.00 $1,457.00 $2,235.00 $1,338.00 $1,701.00 $138.00 $64.00 $470.00 $247.00 -------$857.00 $1,384.00 $1,557.00 $1,998.00 $554.00 $726.00 -------$1,480.00 $10,980.00 $1,517.00 $1,661.00 $1,568.00 $1,390.00 $2,162.00 -------$120.00 $591.00 $585.00 $588.00 $906.00 $1,012.00 $663.00 $485.00


Part B, 224



90 90 90 90 90 90 90 YYY 10 10 10 10 0 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 YYY 10 10 90 90 90 90 10 90 90 90 90 0 10 10 10 10 90 90 90 10 90

$436.00 $529.00 $1,009.00 $1,452.00 $1,030.00 $1,107.00 $1,202.00 BR $110.00 $208.00 $105.00 $245.00 $38.00 $100.00 $141.00 $202.00 $319.00 $336.00 $249.00 $208.00 $104.00 $140.00 $213.00 $687.00 $684.00 $947.00 $1,232.00 $1,593.00 BR $119.00 $109.00 $237.00 $283.00 $248.00 $319.00 $91.00 $267.00 $357.00 $300.00 $424.00 -------$140.00 $136.00 $110.00 $159.00 $255.00 $301.00 $682.00 $176.00 $242.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$696.00 $816.00 $1,327.00 $1,492.00 $1,235.00 $1,497.00 $1,585.00 -------$304.00 $457.00 $273.00 $523.00 $159.00 $267.00 $297.00 $418.00 $560.00 $585.00 $514.00 $458.00 $379.00 $381.00 $485.00 $1,180.00 $1,135.00 $1,580.00 $1,894.00 $2,133.00 -------$235.00 $325.00 $518.00 $506.00 $550.00 $584.00 $289.00 $657.00 $642.00 $648.00 $739.00 $681.00 $243.00 $247.00 $213.00 $305.00 $485.00 $531.00 $937.00 $357.00 $478.00

$742.00 $869.00 $1,403.00 $1,574.00 $1,287.00 $1,591.00 $1,684.00 -------$325.00 $487.00 $291.00 $553.00 $170.00 $285.00 $316.00 $446.00 $597.00 $623.00 $547.00 $489.00 $405.00 $406.00 $517.00 $1,255.00 $1,204.00 $1,681.00 $2,007.00 $2,262.00 -------$250.00 $347.00 $551.00 $538.00 $586.00 $623.00 $309.00 $700.00 $684.00 $690.00 $787.00 $709.00 $258.00 $263.00 $227.00 $325.00 $517.00 $566.00 $994.00 $381.00 $510.00

$770.00 $906.00 $1,484.00 $1,667.00 $1,324.00 $1,690.00 $1,791.00 -------$334.00 $505.00 $299.00 $559.00 $172.00 $292.00 $325.00 $462.00 $621.00 $648.00 $562.00 $507.00 $414.00 $417.00 $534.00 $1,314.00 $1,258.00 $1,767.00 $2,102.00 $2,379.00 -------$259.00 $355.00 $571.00 $557.00 $610.00 $647.00 $316.00 $728.00 $712.00 $719.00 $822.00 $736.00 $267.00 $272.00 $234.00 $335.00 $535.00 $588.00 $1,049.00 $393.00 $526.00

$512.00 $620.00 $1,327.00 $1,492.00 $1,235.00 $1,497.00 $1,585.00 -------$192.00 $328.00 $171.00 $321.00 $46.00 $158.00 $187.00 $292.00 $450.00 $467.00 $396.00 $353.00 $250.00 $241.00 $329.00 $928.00 $889.00 $1,260.00 $1,548.00 $1,809.00 -------$165.00 $183.00 $371.00 $357.00 $399.00 $433.00 $158.00 $517.00 $519.00 $522.00 $612.00 $681.00 $159.00 $164.00 $133.00 $193.00 $372.00 $413.00 $937.00 $225.00 $324.00

$543.00 $659.00 $1,403.00 $1,574.00 $1,287.00 $1,591.00 $1,684.00 -------$205.00 $349.00 $182.00 $337.00 $49.00 $169.00 $199.00 $310.00 $479.00 $497.00 $420.00 $377.00 $266.00 $256.00 $350.00 $985.00 $941.00 $1,338.00 $1,636.00 $1,915.00 -------$176.00 $194.00 $393.00 $378.00 $424.00 $460.00 $167.00 $550.00 $552.00 $555.00 $650.00 $709.00 $169.00 $175.00 $142.00 $205.00 $396.00 $439.00 $994.00 $239.00 $344.00

$571.00 $695.00 $1,484.00 $1,667.00 $1,324.00 $1,690.00 $1,791.00 -------$213.00 $366.00 $189.00 $342.00 $50.00 $175.00 $207.00 $326.00 $502.00 $521.00 $435.00 $394.00 $274.00 $267.00 $366.00 $1,043.00 $994.00 $1,423.00 $1,730.00 $2,031.00 -------$184.00 $202.00 $413.00 $396.00 $447.00 $484.00 $174.00 $577.00 $580.00 $583.00 $685.00 $736.00 $177.00 $184.00 $148.00 $214.00 $414.00 $460.00 $1,049.00 $251.00 $360.00


Part B, 225



90 90 90 90 90 90 90 90 10 10 10 90 90 90 90 0 YYY 10 10 10 0 0 10 90 10 10 90 10 10 0 0 90 90 YYY 10 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90

$813.00 $937.00 $1,869.00 $2,005.00 $2,406.00 $1,897.00 $2,091.00 $2,448.00 $168.00 $203.00 $294.00 $334.00 $313.00 -------$255.00 -------BR $107.00 $115.00 $217.00 NC NC $237.00 $312.00 $144.00 $211.00 $322.00 $176.00 $156.00 NC NC $249.00 $193.00 BR $106.00 $122.00 $161.00 $204.00 $409.00 $573.00 $174.00 $741.00 $176.00 $222.00 $324.00 $946.00 $863.00 $1,174.00 $766.00 $586.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,580.00 $1,952.00 $3,221.00 $3,242.00 $4,127.00 $3,267.00 $3,561.00 $4,477.00 $383.00 $419.00 $455.00 $599.00 $611.00 $968.00 $513.00 $1,394.00 -------$386.00 $369.00 $514.00 BR BR $425.00 $623.00 $305.00 $457.00 $640.00 $452.00 $574.00 BR BR $531.00 $547.00 -------$229.00 $217.00 $311.00 $396.00 $671.00 $1,494.00 $363.00 $1,032.00 $334.00 $354.00 $466.00 $1,249.00 $1,304.00 $1,457.00 $962.00 $729.00

$1,680.00 $2,073.00 $3,414.00 $3,437.00 $4,377.00 $3,463.00 $3,773.00 $4,744.00 $408.00 $447.00 $484.00 $635.00 $650.00 $1,028.00 $547.00 $1,491.00 -------$412.00 $395.00 $548.00 BR BR $453.00 $664.00 $325.00 $487.00 $682.00 $482.00 $612.00 BR BR $565.00 $584.00 -------$244.00 $231.00 $332.00 $422.00 $715.00 $1,587.00 $387.00 $1,093.00 $356.00 $376.00 $495.00 $1,322.00 $1,380.00 $1,542.00 $1,020.00 $770.00

$1,747.00 $2,166.00 $3,593.00 $3,605.00 $4,607.00 $3,638.00 $3,969.00 $5,010.00 $419.00 $462.00 $503.00 $654.00 $670.00 $1,069.00 $567.00 $1,514.00 -------$420.00 $404.00 $568.00 BR BR $470.00 $690.00 $335.00 $504.00 $707.00 $503.00 $636.00 BR BR $584.00 $606.00 -------$252.00 $240.00 $342.00 $437.00 $743.00 $1,658.00 $398.00 $1,149.00 $368.00 $391.00 $518.00 $1,394.00 $1,458.00 $1,631.00 $1,073.00 $810.00

$1,580.00 $1,952.00 $3,221.00 $3,242.00 $4,127.00 $3,267.00 $3,561.00 $4,477.00 $224.00 $268.00 $310.00 $599.00 $611.00 $968.00 $380.00 $547.00 -------$213.00 $254.00 $384.00 BR BR $271.00 $479.00 $180.00 $314.00 $455.00 $318.00 $423.00 BR BR $378.00 $380.00 -------$152.00 $161.00 $205.00 $264.00 $512.00 $1,494.00 $226.00 $1,032.00 $216.00 $271.00 $377.00 $1,249.00 $1,304.00 $1,457.00 $962.00 $729.00

$1,680.00 $2,073.00 $3,414.00 $3,437.00 $4,377.00 $3,463.00 $3,773.00 $4,744.00 $238.00 $285.00 $329.00 $635.00 $650.00 $1,028.00 $405.00 $582.00 -------$226.00 $271.00 $409.00 BR BR $288.00 $509.00 $192.00 $334.00 $483.00 $338.00 $450.00 BR BR $402.00 $405.00 -------$162.00 $171.00 $218.00 $280.00 $544.00 $1,587.00 $240.00 $1,093.00 $229.00 $287.00 $399.00 $1,322.00 $1,380.00 $1,542.00 $1,020.00 $770.00

$1,747.00 $2,166.00 $3,593.00 $3,605.00 $4,607.00 $3,638.00 $3,969.00 $5,010.00 $248.00 $300.00 $347.00 $654.00 $670.00 $1,069.00 $424.00 $603.00 -------$234.00 $280.00 $428.00 BR BR $305.00 $535.00 $201.00 $350.00 $508.00 $359.00 $473.00 BR BR $421.00 $426.00 -------$169.00 $180.00 $228.00 $294.00 $572.00 $1,658.00 $250.00 $1,149.00 $241.00 $301.00 $422.00 $1,394.00 $1,458.00 $1,631.00 $1,073.00 $810.00


Part B, 226



90 90 90 90 90 10 10 YYY 10 90 10 10 10 90 90 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 0 90 YYY 10 10 90 10 10 10 10 10 90 90 90 90 90

$803.00 $848.00 $762.00 $631.00 $491.00 $148.00 $160.00 BR $165.00 $448.00 $145.00 $208.00 $184.00 $287.00 $411.00 $94.00 $258.00 $377.00 $266.00 $746.00 $1,364.00 $1,577.00 $1,097.00 $1,882.00 $634.00 $395.00 $407.00 $559.00 $522.00 $915.00 $711.00 $82.00 $445.00 $67.00 $89.00 $238.00 BR $144.00 $270.00 $720.00 $123.00 $136.00 $167.00 $250.00 $152.00 $335.00 $659.00 $378.00 $320.00 $235.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,277.00 $1,307.00 $1,244.00 $1,066.00 $1,187.00 $240.00 $296.00 -------$303.00 $635.00 $233.00 $361.00 $336.00 $541.00 $671.00 $151.00 $433.00 $654.00 $478.00 $917.00 $1,556.00 $1,749.00 $1,231.00 $1,991.00 $606.00 $654.00 $628.00 $807.00 $753.00 $1,237.00 $940.00 $191.00 $692.00 $120.00 $187.00 $445.00 -------$273.00 $664.00 $1,205.00 $228.00 $279.00 $315.00 $328.00 $291.00 $557.00 $817.00 $442.00 $368.00 $327.00

$1,355.00 $1,388.00 $1,323.00 $1,132.00 $1,259.00 $256.00 $315.00 -------$322.00 $673.00 $247.00 $384.00 $357.00 $576.00 $713.00 $160.00 $459.00 $694.00 $509.00 $973.00 $1,646.00 $1,850.00 $1,303.00 $2,105.00 $641.00 $696.00 $668.00 $857.00 $800.00 $1,310.00 $998.00 $202.00 $735.00 $128.00 $202.00 $473.00 -------$290.00 $704.00 $1,277.00 $243.00 $298.00 $335.00 $349.00 $310.00 $593.00 $867.00 $468.00 $390.00 $346.00

$1,412.00 $1,449.00 $1,389.00 $1,177.00 $1,319.00 $267.00 $327.00 -------$334.00 $711.00 $256.00 $398.00 $370.00 $597.00 $741.00 $164.00 $479.00 $722.00 $526.00 $1,034.00 $1,746.00 $1,964.00 $1,382.00 $2,239.00 $678.00 $724.00 $694.00 $894.00 $840.00 $1,378.00 $1,049.00 $206.00 $764.00 $133.00 $216.00 $490.00 -------$300.00 $741.00 $1,353.00 $252.00 $306.00 $345.00 $363.00 $321.00 $613.00 $910.00 $493.00 $410.00 $363.00

$1,277.00 $1,307.00 $1,244.00 $1,066.00 $979.00 $163.00 $221.00 -------$224.00 $635.00 $181.00 $257.00 $242.00 $379.00 $493.00 $80.00 $333.00 $478.00 $324.00 $917.00 $1,556.00 $1,749.00 $1,231.00 $1,991.00 $606.00 $525.00 $502.00 $666.00 $753.00 $1,237.00 $940.00 $93.00 $510.00 $86.00 $134.00 $300.00 -------$198.00 $579.00 $1,205.00 $163.00 $165.00 $193.00 $238.00 $180.00 $421.00 $817.00 $442.00 $368.00 $327.00

$1,355.00 $1,388.00 $1,323.00 $1,132.00 $1,036.00 $174.00 $235.00 -------$237.00 $673.00 $192.00 $273.00 $257.00 $402.00 $522.00 $85.00 $352.00 $506.00 $343.00 $973.00 $1,646.00 $1,850.00 $1,303.00 $2,105.00 $641.00 $557.00 $532.00 $705.00 $800.00 $1,310.00 $998.00 $96.00 $540.00 $91.00 $145.00 $318.00 -------$210.00 $613.00 $1,277.00 $173.00 $175.00 $205.00 $252.00 $190.00 $446.00 $867.00 $468.00 $390.00 $346.00

$1,412.00 $1,449.00 $1,389.00 $1,177.00 $1,095.00 $184.00 $246.00 -------$249.00 $711.00 $201.00 $287.00 $270.00 $422.00 $549.00 $88.00 $371.00 $533.00 $360.00 $1,034.00 $1,746.00 $1,964.00 $1,382.00 $2,239.00 $678.00 $585.00 $559.00 $743.00 $840.00 $1,378.00 $1,049.00 $101.00 $569.00 $95.00 $158.00 $334.00 -------$219.00 $649.00 $1,353.00 $182.00 $183.00 $214.00 $266.00 $201.00 $466.00 $910.00 $493.00 $410.00 $363.00


Part B, 227



90 90 90 90 90 90 90 90 90 10 90 90 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0

$286.00 $729.00 $1,173.00 $1,958.00 $207.00 $427.00 $1,047.00 $1,262.00 $1,825.00 $429.00 $745.00 $752.00 $561.00 $178.00 $406.00 $602.00 $284.00 $472.00 $562.00 BR $696.00 $712.00 $1,574.00 $744.00 $1,248.00 $2,325.00 $2,664.00 $2,471.00 $2,755.00 $2,509.00 $2,469.00 $2,607.00 $2,350.00 $2,287.00 $2,661.00 $2,242.00 $1,020.00 $1,332.00 ---------------------------------------------------------------$266.00 $245.00 $205.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$352.00 $1,493.00 $2,050.00 $3,320.00 $274.00 $873.00 $2,119.00 $2,804.00 $3,526.00 $497.00 $1,197.00 $1,439.00 $1,131.00 $249.00 $621.00 $760.00 $587.00 $670.00 $751.00 -------$786.00 $765.00 $1,964.00 $918.00 $1,530.00 $3,853.00 $6,905.00 $4,074.00 $6,836.00 $7,481.00 $3,732.00 $5,586.00 $4,349.00 $3,869.00 $7,141.00 $5,787.00 $1,165.00 $2,239.00 $811.00 $227.00 $251.00 $250.00 $288.00 $272.00 $292.00 $267.00 $298.00 $380.00 $387.00 $505.00

$373.00 $1,584.00 $2,174.00 $3,514.00 $291.00 $928.00 $2,246.00 $2,972.00 $3,734.00 $525.00 $1,272.00 $1,531.00 $1,201.00 $264.00 $658.00 $805.00 $618.00 $710.00 $795.00 -------$841.00 $810.00 $2,107.00 $971.00 $1,640.00 $4,132.00 $7,377.00 $4,369.00 $7,314.00 $7,878.00 $4,002.00 $5,985.00 $4,666.00 $4,148.00 $7,658.00 $6,197.00 $1,237.00 $2,397.00 $857.00 $240.00 $265.00 $265.00 $305.00 $288.00 $309.00 $285.00 $317.00 $405.00 $412.00 $539.00

$392.00 $1,656.00 $2,276.00 $3,700.00 $304.00 $960.00 $2,356.00 $3,126.00 $3,928.00 $555.00 $1,322.00 $1,589.00 $1,247.00 $278.00 $692.00 $847.00 $642.00 $750.00 $839.00 -------$910.00 $860.00 $2,312.00 $1,028.00 $1,798.00 $4,542.00 $8,072.00 $4,811.00 $8,013.00 $8,374.00 $4,406.00 $6,594.00 $5,146.00 $4,555.00 $8,428.00 $6,814.00 $1,322.00 $2,629.00 $908.00 $255.00 $281.00 $281.00 $328.00 $305.00 $329.00 $294.00 $329.00 $415.00 $423.00 $551.00

$352.00 $1,493.00 $2,050.00 $3,320.00 $274.00 $873.00 $2,119.00 $2,804.00 $3,526.00 $497.00 $1,197.00 $1,439.00 $1,131.00 $249.00 $621.00 $760.00 $587.00 $670.00 $751.00 -------$786.00 $765.00 $1,964.00 $918.00 $1,530.00 $3,853.00 $6,905.00 $4,074.00 $6,836.00 $7,481.00 $3,732.00 $5,586.00 $4,349.00 $3,869.00 $7,141.00 $5,787.00 $1,165.00 $2,239.00 $811.00 $227.00 $251.00 $250.00 $288.00 $272.00 $292.00 $123.00 $148.00 $139.00 $161.00 $161.00

$373.00 $1,584.00 $2,174.00 $3,514.00 $291.00 $928.00 $2,246.00 $2,972.00 $3,734.00 $525.00 $1,272.00 $1,531.00 $1,201.00 $264.00 $658.00 $805.00 $618.00 $710.00 $795.00 -------$841.00 $810.00 $2,107.00 $971.00 $1,640.00 $4,132.00 $7,377.00 $4,369.00 $7,314.00 $7,878.00 $4,002.00 $5,985.00 $4,666.00 $4,148.00 $7,658.00 $6,197.00 $1,237.00 $2,397.00 $857.00 $240.00 $265.00 $265.00 $305.00 $288.00 $309.00 $130.00 $156.00 $147.00 $170.00 $171.00

$392.00 $1,656.00 $2,276.00 $3,700.00 $304.00 $960.00 $2,356.00 $3,126.00 $3,928.00 $555.00 $1,322.00 $1,589.00 $1,247.00 $278.00 $692.00 $847.00 $642.00 $750.00 $839.00 -------$910.00 $860.00 $2,312.00 $1,028.00 $1,798.00 $4,542.00 $8,072.00 $4,811.00 $8,013.00 $8,374.00 $4,406.00 $6,594.00 $5,146.00 $4,555.00 $8,428.00 $6,814.00 $1,322.00 $2,629.00 $908.00 $255.00 $281.00 $281.00 $328.00 $305.00 $329.00 $139.00 $167.00 $156.00 $181.00 $181.00


Part B, 228



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ

$228.00 $207.00 ------------------------------------------$160.00 $149.00 $176.00 $128.00 $142.00 $218.00 -------$182.00 $252.00 -------$239.00 $285.00 --------------$246.00 $369.00 $157.00 $384.00 $276.00 $268.00 $214.00 $485.00 $229.00 $191.00 $175.00 $194.00 $224.00 ---------------------$343.00 -------$271.00 $349.00 $362.00 $447.00 $386.00 $522.00 $527.00 ----------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$209.00 $217.00 $463.00 $630.00 $359.00 $293.00 $1,693.00 $294.00 $586.00 $576.00 $625.00 $1,557.00 $532.00 $963.00 $1,002.00 $560.00 $669.00 $348.00 $435.00 $540.00 $299.00 $355.00 $554.00 $594.00 $220.00 $400.00 $362.00 $374.00 $853.00 $307.00 $583.00 $571.00 $1,478.00 $637.00 $697.00 $516.00 $399.00 $412.00 $1,012.00 $356.00 $345.00 $489.00 $513.00 $541.00 $542.00 $551.00 $655.00 $346.00 $1,045.00 $179.00

$220.00 $229.00 $493.00 $663.00 $378.00 $311.00 $1,809.00 $309.00 $625.00 $614.00 $666.00 $1,667.00 $567.00 $1,028.00 $1,070.00 $596.00 $711.00 $367.00 $463.00 $576.00 $315.00 $373.00 $590.00 $625.00 $233.00 $421.00 $381.00 $393.00 $911.00 $325.00 $621.00 $608.00 $1,581.00 $680.00 $742.00 $549.00 $420.00 $434.00 $1,080.00 $375.00 $363.00 $514.00 $540.00 $569.00 $570.00 $580.00 $688.00 $365.00 $1,114.00 $188.00

$232.00 $242.00 $508.00 $702.00 $400.00 $335.00 $1,838.00 $328.00 $642.00 $628.00 $685.00 $1,683.00 $583.00 $1,047.00 $1,091.00 $612.00 $730.00 $390.00 $476.00 $590.00 $333.00 $395.00 $605.00 $662.00 $247.00 $445.00 $404.00 $416.00 $932.00 $347.00 $640.00 $624.00 $1,600.00 $699.00 $762.00 $566.00 $443.00 $459.00 $1,101.00 $397.00 $383.00 $544.00 $572.00 $602.00 $604.00 $613.00 $729.00 $388.00 $1,138.00 $199.00

$209.00 $217.00 $209.00 $630.00 $359.00 $293.00 $393.00 $294.00 $220.00 $207.00 $248.00 $184.00 $203.00 $254.00 $302.00 $246.00 $303.00 $348.00 $190.00 $214.00 $299.00 $355.00 $215.00 $594.00 $220.00 $400.00 $362.00 $374.00 $271.00 $307.00 $272.00 $256.00 $236.00 $262.00 $301.00 $259.00 $399.00 $412.00 $307.00 $356.00 $345.00 $489.00 $513.00 $541.00 $542.00 $551.00 $655.00 $346.00 $355.00 $179.00

$220.00 $229.00 $220.00 $663.00 $378.00 $311.00 $414.00 $309.00 $233.00 $218.00 $262.00 $194.00 $215.00 $268.00 $319.00 $259.00 $318.00 $367.00 $201.00 $226.00 $315.00 $373.00 $226.00 $625.00 $233.00 $421.00 $381.00 $393.00 $286.00 $325.00 $287.00 $269.00 $249.00 $277.00 $317.00 $273.00 $420.00 $434.00 $323.00 $375.00 $363.00 $514.00 $540.00 $569.00 $570.00 $580.00 $688.00 $365.00 $373.00 $188.00

$232.00 $242.00 $234.00 $702.00 $400.00 $335.00 $439.00 $328.00 $249.00 $230.00 $280.00 $206.00 $229.00 $284.00 $338.00 $274.00 $335.00 $390.00 $212.00 $239.00 $333.00 $395.00 $240.00 $662.00 $247.00 $445.00 $404.00 $416.00 $305.00 $347.00 $305.00 $284.00 $264.00 $296.00 $336.00 $290.00 $443.00 $459.00 $342.00 $397.00 $383.00 $544.00 $572.00 $602.00 $604.00 $613.00 $729.00 $388.00 $395.00 $199.00


Part B, 229



0 0 0 0 0 90 90 90 90 ZZZ YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 YYY 90 90

------------------------------------------$1,314.00 ---------------------BR $837.00 $1,428.00 $2,138.00 $2,331.00 $2,632.00 $2,891.00 $1,299.00 $1,261.00 --------------$1,236.00 $1,378.00 -------------------------------------------------$1,292.00 $1,351.00 $1,180.00 $1,028.00 $2,277.00 $2,596.00 $1,261.00 $1,299.00 $1,330.00 $946.00 $1,382.00 $854.00 $1,338.00 $91.00 $102.00 $203.00 BR BR $649.00 $1,105.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$699.00 $570.00 $728.00 $573.00 $654.00 $1,945.00 $1,623.00 $2,325.00 $2,614.00 $241.00 -------$905.00 $1,620.00 $2,248.00 $2,446.00 $3,997.00 $4,615.00 $2,092.00 $2,011.00 $1,229.00 $1,712.00 $1,994.00 $2,025.00 $1,745.00 $1,903.00 $1,892.00 $2,030.00 $2,276.00 $2,455.00 $177.00 $2,049.00 $2,121.00 $1,930.00 $1,608.00 $3,559.00 $3,860.00 $2,185.00 $2,347.00 $2,200.00 $1,572.00 $3,882.00 $1,497.00 $2,164.00 $295.00 $1,328.00 $317.00 --------------$1,171.00 $2,017.00

$735.00 $600.00 $766.00 $603.00 $688.00 $2,086.00 $1,741.00 $2,493.00 $2,803.00 $258.00 -------$958.00 $1,715.00 $2,412.00 $2,621.00 $4,213.00 $4,914.00 $2,245.00 $2,156.00 $1,319.00 $1,835.00 $2,139.00 $2,170.00 $1,872.00 $2,041.00 $2,028.00 $2,176.00 $2,439.00 $2,634.00 $190.00 $2,197.00 $2,275.00 $2,061.00 $1,724.00 $3,817.00 $4,137.00 $2,301.00 $2,519.00 $2,360.00 $1,686.00 $4,160.00 $1,581.00 $2,314.00 $314.00 $1,422.00 $334.00 --------------$1,253.00 $2,162.00

$778.00 $635.00 $810.00 $638.00 $728.00 $2,291.00 $1,909.00 $2,739.00 $3,080.00 $285.00 -------$1,011.00 $1,823.00 $2,656.00 $2,888.00 $4,474.00 $5,321.00 $2,465.00 $2,362.00 $1,443.00 $2,018.00 $2,344.00 $2,380.00 $2,054.00 $2,240.00 $2,231.00 $2,397.00 $2,675.00 $2,894.00 $210.00 $2,410.00 $2,501.00 $2,243.00 $1,887.00 $4,187.00 $4,552.00 $2,433.00 $2,772.00 $2,591.00 $1,840.00 $4,571.00 $1,676.00 $2,528.00 $322.00 $1,433.00 $353.00 --------------$1,367.00 $2,370.00

$699.00 $570.00 $728.00 $573.00 $654.00 $1,945.00 $1,623.00 $2,325.00 $2,614.00 $241.00 -------$905.00 $1,620.00 $2,248.00 $2,446.00 $3,997.00 $4,615.00 $2,092.00 $2,011.00 $1,229.00 $1,712.00 $1,994.00 $2,025.00 $1,745.00 $1,903.00 $1,892.00 $2,030.00 $2,276.00 $2,455.00 $177.00 $2,049.00 $2,121.00 $1,930.00 $1,608.00 $3,559.00 $3,860.00 $2,185.00 $2,347.00 $2,200.00 $1,572.00 $3,882.00 $1,497.00 $2,164.00 $125.00 $135.00 $317.00 --------------$1,171.00 $2,017.00

$735.00 $600.00 $766.00 $603.00 $688.00 $2,086.00 $1,741.00 $2,493.00 $2,803.00 $258.00 -------$958.00 $1,715.00 $2,412.00 $2,621.00 $4,213.00 $4,914.00 $2,245.00 $2,156.00 $1,319.00 $1,835.00 $2,139.00 $2,170.00 $1,872.00 $2,041.00 $2,028.00 $2,176.00 $2,439.00 $2,634.00 $190.00 $2,197.00 $2,275.00 $2,061.00 $1,724.00 $3,817.00 $4,137.00 $2,301.00 $2,519.00 $2,360.00 $1,686.00 $4,160.00 $1,581.00 $2,314.00 $132.00 $142.00 $334.00 --------------$1,253.00 $2,162.00

$778.00 $635.00 $810.00 $638.00 $728.00 $2,291.00 $1,909.00 $2,739.00 $3,080.00 $285.00 -------$1,011.00 $1,823.00 $2,656.00 $2,888.00 $4,474.00 $5,321.00 $2,465.00 $2,362.00 $1,443.00 $2,018.00 $2,344.00 $2,380.00 $2,054.00 $2,240.00 $2,231.00 $2,397.00 $2,675.00 $2,894.00 $210.00 $2,410.00 $2,501.00 $2,243.00 $1,887.00 $4,187.00 $4,552.00 $2,433.00 $2,772.00 $2,591.00 $1,840.00 $4,571.00 $1,676.00 $2,528.00 $139.00 $150.00 $353.00 --------------$1,367.00 $2,370.00


Part B, 230



90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$1,247.00 $680.00 $599.00 $686.00 $861.00 $1,001.00 $1,691.00 $1,718.00 $1,798.00 $1,445.00 $1,443.00 $1,467.00 $1,786.00 $143.00 $1,119.00 $1,138.00 --------------$716.00 $856.00 $617.00 BR BR -----------------------------------$81.00 $107.00 ------------------------------------------$793.00 $846.00 $896.00 $1,128.00 $592.00 $593.00 $904.00 $893.00 $1,249.00 -------$1,528.00 $1,678.00 $1,795.00 $1,425.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,287.00 $1,411.00 $1,029.00 $1,251.00 $1,469.00 $1,834.00 $2,941.00 $3,421.00 $3,492.00 $2,176.00 $3,058.00 $2,889.00 $3,183.00 $170.00 $1,767.00 $1,775.00 $2,603.00 $2,784.00 $971.00 $1,145.00 $851.00 -------$60.00 $32.00 $147.00 $198.00 $284.00 $402.00 $670.00 $169.00 $1,674.00 $1,907.00 $1,421.00 $1,899.00 $1,437.00 $1,660.00 $1,392.00 $1,525.00 $2,012.00 $1,960.00 $1,042.00 $866.00 $1,558.00 $2,038.00 $1,917.00 $2,951.00 $2,422.00 $2,658.00 $2,891.00 $2,428.00

$2,453.00 $1,515.00 $1,103.00 $1,341.00 $1,574.00 $1,967.00 $3,150.00 $3,669.00 $3,749.00 $2,333.00 $3,280.00 $3,098.00 $3,412.00 $183.00 $1,895.00 $1,899.00 $2,791.00 $2,986.00 $1,039.00 $1,230.00 $913.00 -------$62.00 $34.00 $156.00 $212.00 $304.00 $430.00 $718.00 $177.00 $1,796.00 $2,046.00 $1,523.00 $2,034.00 $1,541.00 $1,773.00 $1,493.00 $1,636.00 $2,158.00 $2,103.00 $1,117.00 $929.00 $1,669.00 $2,186.00 $2,056.00 $3,165.00 $2,596.00 $2,842.00 $3,100.00 $2,596.00

$2,694.00 $1,659.00 $1,208.00 $1,466.00 $1,724.00 $2,155.00 $3,458.00 $4,038.00 $4,131.00 $2,559.00 $3,607.00 $3,405.00 $3,748.00 $202.00 $2,076.00 $2,069.00 $3,063.00 $3,280.00 $1,129.00 $1,346.00 $993.00 -------$66.00 $36.00 $158.00 $220.00 $308.00 $437.00 $725.00 $185.00 $1,964.00 $2,240.00 $1,666.00 $2,223.00 $1,686.00 $1,945.00 $1,635.00 $1,792.00 $2,366.00 $2,307.00 $1,216.00 $1,010.00 $1,826.00 $2,396.00 $2,253.00 $3,476.00 $2,848.00 $3,104.00 $3,402.00 $2,831.00

$2,287.00 $1,411.00 $1,029.00 $1,251.00 $1,469.00 $1,834.00 $2,941.00 $3,421.00 $3,492.00 $2,176.00 $3,058.00 $2,889.00 $3,183.00 $170.00 $1,767.00 $1,775.00 $2,603.00 $2,784.00 $971.00 $1,145.00 $851.00 -------$60.00 $32.00 $47.00 $91.00 $75.00 $114.00 $70.00 $151.00 $1,674.00 $1,907.00 $1,421.00 $1,899.00 $1,437.00 $1,660.00 $1,392.00 $1,525.00 $2,012.00 $1,960.00 $1,042.00 $866.00 $1,558.00 $2,038.00 $1,917.00 $2,951.00 $2,422.00 $2,658.00 $2,891.00 $2,428.00

$2,453.00 $1,515.00 $1,103.00 $1,341.00 $1,574.00 $1,967.00 $3,150.00 $3,669.00 $3,749.00 $2,333.00 $3,280.00 $3,098.00 $3,412.00 $183.00 $1,895.00 $1,899.00 $2,791.00 $2,986.00 $1,039.00 $1,230.00 $913.00 -------$62.00 $34.00 $49.00 $97.00 $79.00 $120.00 $73.00 $158.00 $1,796.00 $2,046.00 $1,523.00 $2,034.00 $1,541.00 $1,773.00 $1,493.00 $1,636.00 $2,158.00 $2,103.00 $1,117.00 $929.00 $1,669.00 $2,186.00 $2,056.00 $3,165.00 $2,596.00 $2,842.00 $3,100.00 $2,596.00

$2,694.00 $1,659.00 $1,208.00 $1,466.00 $1,724.00 $2,155.00 $3,458.00 $4,038.00 $4,131.00 $2,559.00 $3,607.00 $3,405.00 $3,748.00 $202.00 $2,076.00 $2,069.00 $3,063.00 $3,280.00 $1,129.00 $1,346.00 $993.00 -------$66.00 $36.00 $51.00 $105.00 $83.00 $126.00 $78.00 $166.00 $1,964.00 $2,240.00 $1,666.00 $2,223.00 $1,686.00 $1,945.00 $1,635.00 $1,792.00 $2,366.00 $2,307.00 $1,216.00 $1,010.00 $1,826.00 $2,396.00 $2,253.00 $3,476.00 $2,848.00 $3,104.00 $3,402.00 $2,831.00


Part B, 231



90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 ZZZ 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ

$1,454.00 $1,435.00 $1,549.00 $590.00 $1,352.00 ---------------------BR $1,171.00 $809.00 $1,171.00 $891.00 $888.00 $905.00 $862.00 $957.00 $117.00 $784.00 $963.00 $1,078.00 $308.00 $1,135.00 $1,951.00 $2,243.00 $242.00 $938.00 BR BR $154.00 $1,350.00 $1,488.00 $1,536.00 $1,442.00 $1,678.00 $1,840.00 $1,452.00 $1,661.00 $1,499.00 $1,892.00 $1,709.00 --------------$1,236.00 ----------------------------$1,603.00 $235.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,456.00 $2,456.00 $2,559.00 $1,063.00 $2,400.00 $532.00 $478.00 $678.00 -------$1,640.00 $1,286.00 $216.00 $1,460.00 $1,458.00 $1,476.00 $1,402.00 $2,239.00 $161.00 $1,274.00 $1,472.00 $1,836.00 $366.00 $1,770.00 $3,711.00 $4,256.00 $371.00 $1,967.00 --------------$183.00 $2,010.00 $2,732.00 $2,494.00 $2,656.00 $2,483.00 $3,163.00 $2,919.00 $2,790.00 $3,200.00 $3,102.00 $3,436.00 $3,215.00 $3,140.00 $1,860.00 $1,374.00 $975.00 $1,640.00 $1,824.00 $2,080.00 $364.00

$2,618.00 $2,632.00 $2,744.00 $1,139.00 $2,572.00 $571.00 $512.00 $727.00 -------$1,757.00 $1,373.00 $231.00 $1,565.00 $1,562.00 $1,580.00 $1,503.00 $2,398.00 $169.00 $1,365.00 $1,574.00 $1,967.00 $392.00 $1,894.00 $3,983.00 $4,558.00 $398.00 $2,106.00 --------------$196.00 $2,153.00 $2,926.00 $2,671.00 $2,844.00 $2,654.00 $3,379.00 $3,124.00 $2,985.00 $3,427.00 $3,309.00 $3,680.00 $3,436.00 $3,318.00 $1,991.00 $1,472.00 $1,046.00 $1,750.00 $1,951.00 $2,228.00 $390.00

$2,842.00 $2,888.00 $3,013.00 $1,242.00 $2,821.00 $614.00 $553.00 $787.00 -------$1,925.00 $1,491.00 $255.00 $1,714.00 $1,707.00 $1,727.00 $1,645.00 $2,627.00 $180.00 $1,491.00 $1,717.00 $2,156.00 $432.00 $2,071.00 $4,381.00 $4,999.00 $440.00 $2,304.00 --------------$216.00 $2,356.00 $3,194.00 $2,921.00 $3,112.00 $2,896.00 $3,675.00 $3,422.00 $3,248.00 $3,740.00 $3,585.00 $4,016.00 $3,736.00 $3,533.00 $2,176.00 $1,608.00 $1,143.00 $1,889.00 $2,116.00 $2,438.00 $428.00

$2,456.00 $2,456.00 $2,559.00 $1,063.00 $2,400.00 $532.00 $478.00 $678.00 -------$1,640.00 $1,286.00 $216.00 $1,460.00 $1,458.00 $1,476.00 $1,402.00 $2,239.00 $161.00 $1,274.00 $1,472.00 $1,836.00 $366.00 $1,770.00 $3,711.00 $4,256.00 $371.00 $1,967.00 --------------$183.00 $2,010.00 $2,732.00 $2,494.00 $2,656.00 $2,483.00 $3,163.00 $2,919.00 $2,790.00 $3,200.00 $3,102.00 $3,436.00 $3,215.00 $3,140.00 $1,860.00 $1,374.00 $975.00 $1,640.00 $1,824.00 $2,080.00 $364.00

$2,618.00 $2,632.00 $2,744.00 $1,139.00 $2,572.00 $571.00 $512.00 $727.00 -------$1,757.00 $1,373.00 $231.00 $1,565.00 $1,562.00 $1,580.00 $1,503.00 $2,398.00 $169.00 $1,365.00 $1,574.00 $1,967.00 $392.00 $1,894.00 $3,983.00 $4,558.00 $398.00 $2,106.00 --------------$196.00 $2,153.00 $2,926.00 $2,671.00 $2,844.00 $2,654.00 $3,379.00 $3,124.00 $2,985.00 $3,427.00 $3,309.00 $3,680.00 $3,436.00 $3,318.00 $1,991.00 $1,472.00 $1,046.00 $1,750.00 $1,951.00 $2,228.00 $390.00

$2,842.00 $2,888.00 $3,013.00 $1,242.00 $2,821.00 $614.00 $553.00 $787.00 -------$1,925.00 $1,491.00 $255.00 $1,714.00 $1,707.00 $1,727.00 $1,645.00 $2,627.00 $180.00 $1,491.00 $1,717.00 $2,156.00 $432.00 $2,071.00 $4,381.00 $4,999.00 $440.00 $2,304.00 --------------$216.00 $2,356.00 $3,194.00 $2,921.00 $3,112.00 $2,896.00 $3,675.00 $3,422.00 $3,248.00 $3,740.00 $3,585.00 $4,016.00 $3,736.00 $3,533.00 $2,176.00 $1,608.00 $1,143.00 $1,889.00 $2,116.00 $2,438.00 $428.00


Part B, 232


Surgery CPT Code FUD 2003 MRA 44204 44205 44206 44207 44208 44210 44211 44212 44213 44227 44238 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44381 44382 44384 44385 44386 44388 44388-53 44389 44390 44391 44392 44394 44401 44402

90 90 90 90 90 90 90 90 ZZZ 90 YYY 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$1,353.00 $1,198.00 $1,480.00 $1,620.00 $1,752.00 $1,551.00 $1,926.00 $1,800.00 --------------BR $697.00 $950.00 $453.00 $892.00 $1,229.00 $1,029.00 $1,015.00 $397.00 $816.00 $923.00 $177.00 $195.00 $213.00 $255.00 $226.00 $300.00 $308.00 $253.00 $301.00 $238.00 $305.00 $320.00 $410.00 $396.00 $91.00 -------$110.00 -------$219.00 $183.00 $326.00 -------$301.00 $319.00 $376.00 $359.00 $395.00 ---------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$2,303.00 $2,001.00 $2,626.00 $2,722.00 $2,965.00 $2,651.00 $3,243.00 $3,038.00 $283.00 $2,500.00 -------$1,260.00 $1,560.00 $873.00 $1,492.00 $2,127.00 $1,795.00 $1,477.00 $927.00 $1,568.00 $1,765.00 $221.00 $244.00 $294.00 $312.00 $273.00 $366.00 $374.00 $406.00 $367.00 $295.00 $432.00 $456.00 $582.00 $619.00 $305.00 $1,372.00 $442.00 $233.00 $338.00 $474.00 $496.00 $246.00 $623.00 $624.00 $1,066.00 $589.00 $662.00 $4,467.00 $401.00

$2,461.00 $2,138.00 $2,808.00 $2,903.00 $3,162.00 $2,823.00 $3,448.00 $3,229.00 $302.00 $2,675.00 -------$1,351.00 $1,667.00 $930.00 $1,591.00 $2,284.00 $1,921.00 $1,585.00 $992.00 $1,676.00 $1,886.00 $233.00 $257.00 $309.00 $328.00 $286.00 $385.00 $394.00 $428.00 $387.00 $311.00 $455.00 $480.00 $612.00 $652.00 $326.00 $1,470.00 $472.00 $245.00 $360.00 $506.00 $529.00 $262.00 $663.00 $663.00 $1,137.00 $627.00 $705.00 $4,787.00 $424.00

$2,683.00 $2,329.00 $3,063.00 $3,158.00 $3,431.00 $3,053.00 $3,719.00 $3,475.00 $330.00 $2,924.00 -------$1,477.00 $1,815.00 $1,002.00 $1,722.00 $2,509.00 $2,095.00 $1,711.00 $1,074.00 $1,822.00 $2,052.00 $246.00 $272.00 $328.00 $347.00 $299.00 $407.00 $416.00 $455.00 $411.00 $331.00 $483.00 $509.00 $648.00 $690.00 $332.00 $1,483.00 $480.00 $258.00 $368.00 $516.00 $548.00 $269.00 $682.00 $684.00 $1,162.00 $650.00 $729.00 $4,826.00 $452.00

$2,303.00 $2,001.00 $2,626.00 $2,722.00 $2,965.00 $2,651.00 $3,243.00 $3,038.00 $283.00 $2,500.00 -------$1,260.00 $1,560.00 $873.00 $1,492.00 $2,127.00 $1,795.00 $1,477.00 $927.00 $1,568.00 $1,765.00 $221.00 $244.00 $294.00 $312.00 $273.00 $366.00 $374.00 $406.00 $367.00 $295.00 $432.00 $456.00 $582.00 $619.00 $91.00 $134.00 $116.00 $233.00 $114.00 $139.00 $242.00 $119.00 $264.00 $322.00 $352.00 $305.00 $346.00 $371.00 $401.00

$2,461.00 $2,138.00 $2,808.00 $2,903.00 $3,162.00 $2,823.00 $3,448.00 $3,229.00 $302.00 $2,675.00 -------$1,351.00 $1,667.00 $930.00 $1,591.00 $2,284.00 $1,921.00 $1,585.00 $992.00 $1,676.00 $1,886.00 $233.00 $257.00 $309.00 $328.00 $286.00 $385.00 $394.00 $428.00 $387.00 $311.00 $455.00 $480.00 $612.00 $652.00 $96.00 $142.00 $123.00 $245.00 $120.00 $147.00 $256.00 $125.00 $279.00 $339.00 $371.00 $322.00 $365.00 $392.00 $424.00

$2,683.00 $2,329.00 $3,063.00 $3,158.00 $3,431.00 $3,053.00 $3,719.00 $3,475.00 $330.00 $2,924.00 -------$1,477.00 $1,815.00 $1,002.00 $1,722.00 $2,509.00 $2,095.00 $1,711.00 $1,074.00 $1,822.00 $2,052.00 $246.00 $272.00 $328.00 $347.00 $299.00 $407.00 $416.00 $455.00 $411.00 $331.00 $483.00 $509.00 $648.00 $690.00 $102.00 $151.00 $129.00 $258.00 $127.00 $156.00 $274.00 $133.00 $297.00 $358.00 $393.00 $344.00 $389.00 $418.00 $452.00


Part B, 233



0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 0 0 0 90 90 90 YYY 90 90 ZZZ 90 90 YYY 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90

------------------------------------------$28.00 $815.00 $1,041.00 $1,027.00 $1,132.00 $994.00 $741.00 $1,277.00 $1,581.00 $1,036.00 $1,076.00 $1,050.00 $1,326.00 $1,049.00 $1,115.00 $161.00 --------------BR $791.00 $755.00 $708.00 BR $644.00 $643.00 $136.00 $790.00 $631.00 BR $329.00 $197.00 $364.00 $321.00 $419.00 $1,801.00 $1,270.00 $1,904.00 $1,885.00 $1,732.00 $1,485.00 $1,911.00 $1,845.00 $1,870.00 $1,126.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$460.00 $598.00 $852.00 $352.00 $422.00 $355.00 $36.00 $2,124.00 $2,432.00 $1,586.00 $1,956.00 $1,612.00 $1,296.00 $1,517.00 $2,407.00 $2,102.00 $2,173.00 $1,976.00 $2,319.00 $1,597.00 $1,518.00 $254.00 $417.00 $584.00 -------$1,137.00 $1,253.00 $1,123.00 -------$1,154.00 $963.00 $127.00 $1,310.00 $897.00 -------$622.00 $390.00 $844.00 $438.00 $541.00 $2,747.00 $1,617.00 $2,797.00 $2,794.00 $2,731.00 $2,466.00 $2,890.00 $2,216.00 $2,605.00 $1,659.00

$486.00 $637.00 $909.00 $372.00 $446.00 $376.00 $37.00 $2,275.00 $2,604.00 $1,698.00 $2,094.00 $1,726.00 $1,385.00 $1,618.00 $2,575.00 $2,248.00 $2,323.00 $2,095.00 $2,473.00 $1,711.00 $1,615.00 $272.00 $448.00 $627.00 -------$1,217.00 $1,341.00 $1,203.00 -------$1,237.00 $1,032.00 $135.00 $1,405.00 $962.00 -------$662.00 $417.00 $902.00 $467.00 $580.00 $2,928.00 $1,726.00 $2,974.00 $2,951.00 $2,931.00 $2,642.00 $3,072.00 $2,339.00 $2,793.00 $1,762.00

$517.00 $657.00 $931.00 $397.00 $476.00 $401.00 $39.00 $2,498.00 $2,854.00 $1,859.00 $2,289.00 $1,887.00 $1,506.00 $1,758.00 $2,818.00 $2,457.00 $2,538.00 $2,257.00 $2,691.00 $1,871.00 $1,747.00 $298.00 $496.00 $694.00 -------$1,323.00 $1,462.00 $1,313.00 -------$1,350.00 $1,130.00 $149.00 $1,540.00 $1,050.00 -------$709.00 $435.00 $973.00 $498.00 $628.00 $3,169.00 $1,873.00 $3,217.00 $3,146.00 $3,221.00 $2,893.00 $3,311.00 $2,490.00 $3,061.00 $1,896.00

$460.00 $266.00 $282.00 $352.00 $422.00 $355.00 $36.00 $2,124.00 $2,432.00 $1,586.00 $1,956.00 $1,612.00 $1,296.00 $1,517.00 $2,407.00 $2,102.00 $2,173.00 $1,976.00 $2,319.00 $1,597.00 $1,518.00 $254.00 $417.00 $584.00 -------$1,137.00 $1,253.00 $1,123.00 -------$1,154.00 $963.00 $127.00 $1,310.00 $897.00 -------$622.00 $236.00 $844.00 $438.00 $541.00 $2,747.00 $1,617.00 $2,797.00 $2,794.00 $2,731.00 $2,466.00 $2,890.00 $2,216.00 $2,605.00 $1,659.00

$486.00 $281.00 $299.00 $372.00 $446.00 $376.00 $37.00 $2,275.00 $2,604.00 $1,698.00 $2,094.00 $1,726.00 $1,385.00 $1,618.00 $2,575.00 $2,248.00 $2,323.00 $2,095.00 $2,473.00 $1,711.00 $1,615.00 $272.00 $448.00 $627.00 -------$1,217.00 $1,341.00 $1,203.00 -------$1,237.00 $1,032.00 $135.00 $1,405.00 $962.00 -------$662.00 $253.00 $902.00 $467.00 $580.00 $2,928.00 $1,726.00 $2,974.00 $2,951.00 $2,931.00 $2,642.00 $3,072.00 $2,339.00 $2,793.00 $1,762.00

$517.00 $300.00 $319.00 $397.00 $476.00 $401.00 $39.00 $2,498.00 $2,854.00 $1,859.00 $2,289.00 $1,887.00 $1,506.00 $1,758.00 $2,818.00 $2,457.00 $2,538.00 $2,257.00 $2,691.00 $1,871.00 $1,747.00 $298.00 $496.00 $694.00 -------$1,323.00 $1,462.00 $1,313.00 -------$1,350.00 $1,130.00 $149.00 $1,540.00 $1,050.00 -------$709.00 $270.00 $973.00 $498.00 $628.00 $3,169.00 $1,873.00 $3,217.00 $3,146.00 $3,221.00 $2,893.00 $3,311.00 $2,490.00 $3,061.00 $1,896.00


Part B, 234



90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90

$2,444.00 $1,041.00 $1,354.00 $1,526.00 $475.00 $949.00 --------------$623.00 $75.00 $72.00 $102.00 $172.00 $137.00 $174.00 $211.00 $209.00 $230.00 $154.00 $96.00 $87.00 $120.00 $174.00 $176.00 $171.00 $144.00 $144.00 $212.00 $328.00 $153.00 $224.00 ----------------------------$415.00 $369.00 $388.00 $481.00 $415.00 $479.00 $739.00 ---------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$4,154.00 $1,610.00 $2,049.00 $2,666.00 $569.00 $1,527.00 $882.00 $1,190.00 $1,019.00 $172.00 $1,321.00 $274.00 $331.00 $304.00 $319.00 $316.00 $343.00 $345.00 $159.00 $183.00 $232.00 $355.00 $433.00 $484.00 $841.00 $400.00 $180.00 $453.00 $675.00 $192.00 $260.00 $4,269.00 $238.00 $304.00 $805.00 $673.00 $657.00 $632.00 $1,104.00 $723.00 $692.00 $913.00 $4,495.00 $442.00 $505.00 $392.00 $462.00 $387.00 $2,935.00 $3,192.00

$4,416.00 $1,709.00 $2,196.00 $2,817.00 $602.00 $1,638.00 $941.00 $1,266.00 $1,083.00 $184.00 $1,416.00 $293.00 $355.00 $326.00 $342.00 $335.00 $366.00 $370.00 $170.00 $196.00 $248.00 $379.00 $462.00 $517.00 $899.00 $427.00 $190.00 $483.00 $722.00 $202.00 $274.00 $4,576.00 $251.00 $321.00 $861.00 $715.00 $699.00 $672.00 $1,177.00 $770.00 $735.00 $973.00 $4,815.00 $466.00 $533.00 $413.00 $487.00 $408.00 $3,122.00 $3,389.00

$4,772.00 $1,835.00 $2,402.00 $2,997.00 $636.00 $1,791.00 $1,006.00 $1,355.00 $1,156.00 $189.00 $1,431.00 $303.00 $372.00 $340.00 $357.00 $341.00 $380.00 $387.00 $184.00 $214.00 $253.00 $386.00 $474.00 $528.00 $912.00 $434.00 $203.00 $495.00 $732.00 $214.00 $290.00 $4,604.00 $266.00 $342.00 $874.00 $740.00 $719.00 $692.00 $1,203.00 $796.00 $761.00 $997.00 $4,856.00 $495.00 $569.00 $437.00 $516.00 $435.00 $3,364.00 $3,641.00

$4,154.00 $1,610.00 $2,049.00 $2,666.00 $569.00 $1,527.00 $882.00 $1,190.00 $1,019.00 $79.00 $136.00 $116.00 $159.00 $133.00 $142.00 $152.00 $173.00 $165.00 $159.00 $183.00 $82.00 $106.00 $165.00 $147.00 $183.00 $106.00 $180.00 $187.00 $123.00 $192.00 $260.00 $247.00 $238.00 $304.00 $157.00 $365.00 $307.00 $307.00 $395.00 $350.00 $388.00 $325.00 $413.00 $442.00 $505.00 $392.00 $462.00 $387.00 $2,935.00 $3,192.00

$4,416.00 $1,709.00 $2,196.00 $2,817.00 $602.00 $1,638.00 $941.00 $1,266.00 $1,083.00 $84.00 $145.00 $124.00 $171.00 $142.00 $152.00 $159.00 $184.00 $177.00 $170.00 $196.00 $87.00 $112.00 $174.00 $156.00 $193.00 $112.00 $190.00 $197.00 $130.00 $202.00 $274.00 $260.00 $251.00 $321.00 $166.00 $385.00 $324.00 $323.00 $416.00 $370.00 $409.00 $342.00 $436.00 $466.00 $533.00 $413.00 $487.00 $408.00 $3,122.00 $3,389.00

$4,772.00 $1,835.00 $2,402.00 $2,997.00 $636.00 $1,791.00 $1,006.00 $1,355.00 $1,156.00 $89.00 $156.00 $133.00 $187.00 $155.00 $165.00 $165.00 $197.00 $193.00 $184.00 $214.00 $92.00 $118.00 $185.00 $166.00 $204.00 $119.00 $203.00 $209.00 $138.00 $214.00 $290.00 $276.00 $266.00 $342.00 $177.00 $409.00 $343.00 $342.00 $440.00 $394.00 $434.00 $364.00 $464.00 $495.00 $569.00 $437.00 $516.00 $435.00 $3,364.00 $3,641.00


Part B, 235



0 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 10 10 10 10 0 YYY 10 10 90 90 10 90 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 0

---------------------$584.00 $510.00 $46.00 $1,009.00 $888.00 $1,350.00 $618.00 $915.00 $1,412.00 $1,050.00 $1,273.00 $1,066.00 $1,241.00 $120.00 $133.00 $163.00 $142.00 -------BR $230.00 $94.00 $393.00 $312.00 $105.00 $482.00 $246.00 $98.00 $323.00 $118.00 $124.00 $198.00 $400.00 $501.00 $504.00 $539.00 $598.00 $655.00 $686.00 $328.00 $442.00 $514.00 $335.00 $521.00 $126.00 $109.00 -------$38.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,021.00 $1,688.00 $2,257.00 $759.00 $870.00 $217.00 $1,570.00 $1,398.00 $2,164.00 $1,003.00 $1,663.00 $2,467.00 $1,782.00 $2,190.00 $1,751.00 $2,033.00 $298.00 $248.00 $285.00 $471.00 $159.00 -------$397.00 $198.00 $769.00 $636.00 $283.00 $696.00 $355.00 $249.00 $631.00 $292.00 $379.00 $389.00 $663.00 $726.00 $617.00 $689.00 $698.00 $766.00 $807.00 $728.00 $769.00 $684.00 $761.00 $804.00 $261.00 $274.00 $410.00 $124.00

$1,090.00 $1,792.00 $2,398.00 $803.00 $927.00 $232.00 $1,669.00 $1,493.00 $2,300.00 $1,057.00 $1,776.00 $2,648.00 $1,895.00 $2,351.00 $1,849.00 $2,143.00 $318.00 $264.00 $303.00 $502.00 $170.00 -------$424.00 $211.00 $822.00 $680.00 $302.00 $743.00 $380.00 $265.00 $674.00 $312.00 $404.00 $415.00 $709.00 $776.00 $658.00 $739.00 $745.00 $815.00 $859.00 $779.00 $820.00 $728.00 $812.00 $856.00 $278.00 $292.00 $437.00 $132.00

$1,118.00 $1,927.00 $2,587.00 $848.00 $991.00 $236.00 $1,798.00 $1,613.00 $2,477.00 $1,116.00 $1,923.00 $2,897.00 $2,041.00 $2,573.00 $1,965.00 $2,273.00 $342.00 $282.00 $322.00 $522.00 $183.00 -------$447.00 $221.00 $867.00 $729.00 $312.00 $792.00 $401.00 $275.00 $701.00 $324.00 $419.00 $435.00 $744.00 $816.00 $703.00 $801.00 $799.00 $872.00 $917.00 $820.00 $860.00 $774.00 $851.00 $913.00 $291.00 $302.00 $460.00 $136.00

$360.00 $1,688.00 $2,257.00 $759.00 $870.00 $58.00 $1,570.00 $1,398.00 $2,164.00 $1,003.00 $1,663.00 $2,467.00 $1,782.00 $2,190.00 $1,751.00 $2,033.00 $298.00 $248.00 $285.00 $330.00 $159.00 -------$342.00 $132.00 $606.00 $636.00 $141.00 $696.00 $236.00 $154.00 $470.00 $173.00 $275.00 $253.00 $462.00 $519.00 $617.00 $689.00 $698.00 $766.00 $807.00 $572.00 $602.00 $684.00 $599.00 $804.00 $162.00 $177.00 $348.00 $59.00

$381.00 $1,792.00 $2,398.00 $803.00 $927.00 $61.00 $1,669.00 $1,493.00 $2,300.00 $1,057.00 $1,776.00 $2,648.00 $1,895.00 $2,351.00 $1,849.00 $2,143.00 $318.00 $264.00 $303.00 $350.00 $170.00 -------$364.00 $140.00 $648.00 $680.00 $151.00 $743.00 $252.00 $164.00 $501.00 $185.00 $292.00 $269.00 $494.00 $554.00 $658.00 $739.00 $745.00 $815.00 $859.00 $611.00 $641.00 $728.00 $638.00 $856.00 $173.00 $189.00 $370.00 $63.00

$407.00 $1,927.00 $2,587.00 $848.00 $991.00 $64.00 $1,798.00 $1,613.00 $2,477.00 $1,116.00 $1,923.00 $2,897.00 $2,041.00 $2,573.00 $1,965.00 $2,273.00 $342.00 $282.00 $322.00 $369.00 $183.00 -------$387.00 $149.00 $692.00 $729.00 $160.00 $792.00 $272.00 $174.00 $528.00 $197.00 $306.00 $288.00 $528.00 $594.00 $703.00 $801.00 $799.00 $872.00 $917.00 $652.00 $681.00 $774.00 $677.00 $913.00 $184.00 $198.00 $393.00 $67.00


Part B, 236



0 0 0 0 0 0 0 0 0 0 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 10 10 10 10 10 90 10 10 90 90 90 YYY 0 ZZZ 90 90 90 90 90

-------$92.00 $66.00 -------$115.00 $114.00 $149.00 $196.00 $169.00 $202.00 $585.00 $140.00 ---------------------$545.00 $906.00 $1,584.00 $1,881.00 $1,671.00 $2,236.00 $2,412.00 $2,725.00 $2,933.00 $636.00 $511.00 $188.00 $846.00 $813.00 $731.00 $128.00 $144.00 $145.00 $228.00 $189.00 $297.00 -------$165.00 $145.00 $199.00 $270.00 -------BR $218.00 $141.00 $788.00 $755.00 $550.00 $1,663.00 $2,512.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$193.00 $851.00 $315.00 $271.00 $325.00 $317.00 $248.00 $362.00 $181.00 $206.00 $958.00 $241.00 $698.00 $1,544.00 $3,156.00 $802.00 $1,617.00 $2,669.00 $3,094.00 $3,209.00 $3,611.00 $5,296.00 $5,373.00 $5,837.00 $1,103.00 $906.00 $416.00 $1,594.00 $1,353.00 $1,356.00 $341.00 $362.00 $323.00 $625.00 $377.00 $744.00 $289.00 $325.00 $306.00 $436.00 $445.00 $564.00 -------$504.00 $157.00 $1,798.00 $1,707.00 $1,257.00 $3,496.00 $5,174.00

$203.00 $912.00 $337.00 $286.00 $348.00 $339.00 $264.00 $388.00 $193.00 $220.00 $1,018.00 $255.00 $745.00 $1,635.00 $3,346.00 $861.00 $1,708.00 $2,815.00 $3,263.00 $3,445.00 $3,851.00 $5,686.00 $5,662.00 $6,150.00 $1,166.00 $973.00 $441.00 $1,684.00 $1,431.00 $1,435.00 $364.00 $387.00 $344.00 $667.00 $403.00 $795.00 $308.00 $346.00 $326.00 $466.00 $475.00 $603.00 -------$536.00 $169.00 $1,926.00 $1,826.00 $1,347.00 $3,750.00 $5,552.00

$208.00 $921.00 $346.00 $294.00 $358.00 $350.00 $273.00 $401.00 $200.00 $231.00 $1,085.00 $269.00 $798.00 $1,740.00 $3,585.00 $934.00 $1,803.00 $2,981.00 $3,458.00 $3,769.00 $4,169.00 $6,249.00 $6,015.00 $6,535.00 $1,238.00 $1,058.00 $458.00 $1,781.00 $1,521.00 $1,524.00 $375.00 $401.00 $354.00 $679.00 $418.00 $814.00 $317.00 $361.00 $339.00 $484.00 $494.00 $650.00 -------$544.00 $186.00 $2,100.00 $1,986.00 $1,467.00 $4,115.00 $6,115.00

$135.00 $97.00 $112.00 $183.00 $120.00 $120.00 $120.00 $139.00 $95.00 $137.00 $958.00 $241.00 $698.00 $1,544.00 $3,156.00 $802.00 $1,617.00 $2,669.00 $3,094.00 $3,209.00 $3,611.00 $5,296.00 $5,373.00 $5,837.00 $1,103.00 $906.00 $329.00 $1,594.00 $1,353.00 $1,356.00 $199.00 $196.00 $207.00 $191.00 $198.00 $268.00 $210.00 $215.00 $192.00 $324.00 $325.00 $564.00 -------$150.00 $157.00 $1,798.00 $1,707.00 $1,257.00 $3,496.00 $5,174.00

$141.00 $103.00 $119.00 $192.00 $127.00 $128.00 $127.00 $148.00 $101.00 $146.00 $1,018.00 $255.00 $745.00 $1,635.00 $3,346.00 $861.00 $1,708.00 $2,815.00 $3,263.00 $3,445.00 $3,851.00 $5,686.00 $5,662.00 $6,150.00 $1,166.00 $973.00 $348.00 $1,684.00 $1,431.00 $1,435.00 $211.00 $208.00 $219.00 $202.00 $211.00 $285.00 $223.00 $227.00 $203.00 $346.00 $347.00 $603.00 -------$157.00 $169.00 $1,926.00 $1,826.00 $1,347.00 $3,750.00 $5,552.00

$146.00 $110.00 $127.00 $200.00 $137.00 $138.00 $136.00 $161.00 $107.00 $157.00 $1,085.00 $269.00 $798.00 $1,740.00 $3,585.00 $934.00 $1,803.00 $2,981.00 $3,458.00 $3,769.00 $4,169.00 $6,249.00 $6,015.00 $6,535.00 $1,238.00 $1,058.00 $364.00 $1,781.00 $1,521.00 $1,524.00 $222.00 $222.00 $229.00 $212.00 $226.00 $303.00 $232.00 $242.00 $216.00 $363.00 $366.00 $650.00 -------$164.00 $186.00 $2,100.00 $1,986.00 $1,467.00 $4,115.00 $6,115.00


Part B, 237



90 90 90 0 0 90 90 90 90 90 90 90 YYY 90 90 10 10 YYY 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ ZZZ 0 0 0 0 0 90 90 90 90 YYY 90

$2,293.00 $2,482.00 $6,164.00 --------------$778.00 $942.00 $1,305.00 $2,129.00 $849.00 $943.00 $889.00 BR $1,107.00 $1,094.00 $660.00 -------BR $1,435.00 $1,222.00 $1,275.00 $1,039.00 $755.00 $467.00 --------------------------------------------------------------------------------------------------$209.00 $364.00 $342.00 $594.00 $383.00 $425.00 $837.00 $900.00 $1,069.00 $961.00 BR $868.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$4,622.00 $4,966.00 $8,061.00 $499.00 $580.00 $1,691.00 $2,049.00 $2,787.00 $4,538.00 $2,172.00 $1,870.00 $1,647.00 -------$2,161.00 $1,949.00 $6,919.00 $10,361.00 -------$3,229.00 $2,010.00 $2,028.00 $1,875.00 $1,301.00 $479.00 $516.00 $1,138.00 $1,855.00 $2,288.00 $1,532.00 $1,127.00 $560.00 $6,184.00 $6,765.00 $7,038.00 $1,637.00 $723.00 $1,833.00 $1,135.00 $251.00 $457.00 $452.00 $708.00 $541.00 $615.00 $982.00 $1,068.00 $1,666.00 $1,145.00 -------$1,598.00

$4,958.00 $5,327.00 $8,647.00 $536.00 $622.00 $1,813.00 $2,196.00 $2,986.00 $4,859.00 $2,331.00 $2,006.00 $1,719.00 -------$2,314.00 $2,033.00 $7,388.00 $11,103.00 -------$3,462.00 $2,156.00 $2,175.00 $2,010.00 $1,395.00 $503.00 $550.00 $1,212.00 $1,979.00 $2,440.00 $1,636.00 $1,202.00 $598.00 $6,620.00 $7,237.00 $7,526.00 $1,745.00 $775.00 $1,967.00 $1,211.00 $269.00 $477.00 $470.00 $746.00 $563.00 $640.00 $1,053.00 $1,146.00 $1,787.00 $1,228.00 -------$1,713.00

$5,452.00 $5,861.00 $9,486.00 $593.00 $687.00 $1,980.00 $2,401.00 $3,269.00 $5,326.00 $2,554.00 $2,199.00 $1,791.00 -------$2,532.00 $2,118.00 $7,459.00 $11,184.00 -------$3,798.00 $2,361.00 $2,382.00 $2,198.00 $1,516.00 $520.00 $558.00 $1,232.00 $2,011.00 $2,482.00 $1,663.00 $1,216.00 $608.00 $6,661.00 $7,287.00 $7,583.00 $1,772.00 $800.00 $2,000.00 $1,235.00 $297.00 $499.00 $492.00 $797.00 $589.00 $670.00 $1,151.00 $1,253.00 $1,955.00 $1,344.00 -------$1,875.00

$4,622.00 $4,966.00 $8,061.00 $499.00 $580.00 $1,691.00 $2,049.00 $2,787.00 $4,538.00 $2,172.00 $1,870.00 $1,647.00 -------$2,161.00 $1,949.00 $1,130.00 $725.00 -------$3,229.00 $2,010.00 $2,028.00 $1,875.00 $1,301.00 $479.00 $140.00 $318.00 $452.00 $600.00 $346.00 $216.00 $147.00 $483.00 $653.00 $780.00 $417.00 $202.00 $254.00 $319.00 $251.00 $457.00 $452.00 $708.00 $541.00 $615.00 $982.00 $1,068.00 $1,666.00 $1,145.00 -------$1,598.00

$4,958.00 $5,327.00 $8,647.00 $536.00 $622.00 $1,813.00 $2,196.00 $2,986.00 $4,859.00 $2,331.00 $2,006.00 $1,719.00 -------$2,314.00 $2,033.00 $1,177.00 $765.00 -------$3,462.00 $2,156.00 $2,175.00 $2,010.00 $1,395.00 $503.00 $147.00 $332.00 $474.00 $628.00 $363.00 $226.00 $155.00 $503.00 $680.00 $812.00 $435.00 $217.00 $272.00 $335.00 $269.00 $477.00 $470.00 $746.00 $563.00 $640.00 $1,053.00 $1,146.00 $1,787.00 $1,228.00 -------$1,713.00

$5,452.00 $5,861.00 $9,486.00 $593.00 $687.00 $1,980.00 $2,401.00 $3,269.00 $5,326.00 $2,554.00 $2,199.00 $1,791.00 -------$2,532.00 $2,118.00 $1,231.00 $816.00 -------$3,798.00 $2,361.00 $2,382.00 $2,198.00 $1,516.00 $520.00 $153.00 $350.00 $502.00 $665.00 $386.00 $236.00 $164.00 $526.00 $711.00 $849.00 $458.00 $240.00 $301.00 $357.00 $297.00 $499.00 $492.00 $797.00 $589.00 $670.00 $1,151.00 $1,253.00 $1,955.00 $1,344.00 -------$1,875.00


Part B, 238



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 90 90 90 90 90 0 90 90

$935.00 $1,164.00 $1,276.00 $1,295.00 $1,111.00 $1,913.00 $1,442.00 $1,793.00 $1,157.00 $1,040.00 $1,248.00 $1,188.00 $1,425.00 $1,568.00 $1,624.00 $1,635.00 $1,871.00 $1,485.00 $906.00 $1,352.00 $1,331.00 BR $1,053.00 $1,305.00 $983.00 $779.00 $341.00 -------$1,083.00 $1,546.00 $1,661.00 $1,830.00 $1,149.00 $3,101.00 $2,888.00 $3,099.00 $2,893.00 $1,855.00 BR $100.00 $1,012.00 $938.00 $1,103.00 $1,350.00 $1,170.00 $1,630.00 --------------$2,365.00 $1,117.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,683.00 $1,882.00 $1,906.00 $2,066.00 $1,549.00 $2,529.00 $2,331.00 $2,984.00 $1,996.00 $1,720.00 $2,033.00 $1,946.00 $2,201.00 $3,394.00 $4,562.00 $3,715.00 $4,887.00 $2,361.00 $1,469.00 $2,258.00 $2,051.00 -------$2,807.00 $3,439.00 $1,753.00 $1,325.00 $749.00 $4,286.00 $1,660.00 $2,346.00 $2,441.00 $2,812.00 $1,865.00 $4,679.00 $4,313.00 $4,653.00 $4,367.00 $2,725.00 -------$156.00 $1,674.00 $1,625.00 $1,638.00 $1,951.00 $1,998.00 $2,688.00 $2,497.00 $354.00 $3,797.00 $1,890.00

$1,806.00 $2,018.00 $2,044.00 $2,217.00 $1,659.00 $2,697.00 $2,500.00 $3,199.00 $2,142.00 $1,846.00 $2,182.00 $2,085.00 $2,360.00 $3,642.00 $4,893.00 $3,984.00 $5,243.00 $2,533.00 $1,549.00 $2,418.00 $2,200.00 -------$3,008.00 $3,684.00 $1,880.00 $1,420.00 $793.00 $4,595.00 $1,780.00 $2,516.00 $2,619.00 $3,017.00 $2,001.00 $5,021.00 $4,626.00 $4,991.00 $4,689.00 $2,926.00 -------$164.00 $1,787.00 $1,742.00 $1,757.00 $2,093.00 $2,142.00 $2,883.00 $2,678.00 $379.00 $4,071.00 $2,027.00

$1,978.00 $2,213.00 $2,242.00 $2,434.00 $1,806.00 $2,926.00 $2,741.00 $3,507.00 $2,348.00 $2,018.00 $2,392.00 $2,277.00 $2,583.00 $4,002.00 $5,379.00 $4,376.00 $5,768.00 $2,777.00 $1,643.00 $2,640.00 $2,408.00 -------$3,297.00 $4,044.00 $2,057.00 $1,551.00 $811.00 $5,047.00 $1,949.00 $2,761.00 $2,875.00 $3,303.00 $2,190.00 $5,518.00 $5,079.00 $5,483.00 $5,155.00 $3,207.00 -------$173.00 $1,934.00 $1,900.00 $1,925.00 $2,297.00 $2,346.00 $3,165.00 $2,938.00 $417.00 $4,421.00 $2,208.00

$1,683.00 $1,882.00 $1,906.00 $2,066.00 $1,549.00 $2,529.00 $2,331.00 $2,984.00 $1,996.00 $1,720.00 $2,033.00 $1,946.00 $2,201.00 $3,394.00 $4,562.00 $3,715.00 $4,887.00 $2,361.00 $1,469.00 $2,258.00 $2,051.00 -------$2,807.00 $3,439.00 $1,753.00 $1,325.00 $355.00 $4,286.00 $1,660.00 $2,346.00 $2,441.00 $2,812.00 $1,865.00 $4,679.00 $4,313.00 $4,653.00 $4,367.00 $2,725.00 -------$156.00 $1,674.00 $1,625.00 $1,638.00 $1,951.00 $1,998.00 $2,688.00 $2,497.00 $354.00 $3,797.00 $1,890.00

$1,806.00 $2,018.00 $2,044.00 $2,217.00 $1,659.00 $2,697.00 $2,500.00 $3,199.00 $2,142.00 $1,846.00 $2,182.00 $2,085.00 $2,360.00 $3,642.00 $4,893.00 $3,984.00 $5,243.00 $2,533.00 $1,549.00 $2,418.00 $2,200.00 -------$3,008.00 $3,684.00 $1,880.00 $1,420.00 $370.00 $4,595.00 $1,780.00 $2,516.00 $2,619.00 $3,017.00 $2,001.00 $5,021.00 $4,626.00 $4,991.00 $4,689.00 $2,926.00 -------$164.00 $1,787.00 $1,742.00 $1,757.00 $2,093.00 $2,142.00 $2,883.00 $2,678.00 $379.00 $4,071.00 $2,027.00

$1,978.00 $2,213.00 $2,242.00 $2,434.00 $1,806.00 $2,926.00 $2,741.00 $3,507.00 $2,348.00 $2,018.00 $2,392.00 $2,277.00 $2,583.00 $4,002.00 $5,379.00 $4,376.00 $5,768.00 $2,777.00 $1,643.00 $2,640.00 $2,408.00 -------$3,297.00 $4,044.00 $2,057.00 $1,551.00 $387.00 $5,047.00 $1,949.00 $2,761.00 $2,875.00 $3,303.00 $2,190.00 $5,518.00 $5,079.00 $5,483.00 $5,155.00 $3,207.00 -------$173.00 $1,934.00 $1,900.00 $1,925.00 $2,297.00 $2,346.00 $3,165.00 $2,938.00 $417.00 $4,421.00 $2,208.00


Part B, 239



YYY 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 10 10 10 90 10 10 ZZZ ZZZ YYY 0 90 0 0 0 0 ZZZ 0 90 0 10 0 0 90 90 0 10 10 ZZZ 10 10

BR $862.00 $784.00 $915.00 $910.00 $763.00 $827.00 $892.00 ---------------------$212.00 ----------------------------$1,551.00 $1,182.00 $622.00 $591.00 $415.00 $443.00 $460.00 $712.00 ----------------------------BR $127.00 -------------------------------------------------$405.00 $452.00 $468.00 $106.00 $54.00 $914.00 $725.00 $48.00 $184.00 $522.00 ----------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

-------$1,151.00 $1,567.00 $1,397.00 $2,382.00 $1,494.00 $1,645.00 $1,097.00 $268.00 $410.00 $163.00 $230.00 $1,369.00 $1,787.00 $2,289.00 $2,632.00 $3,315.00 $1,302.00 $872.00 $1,176.00 $482.00 $512.00 $544.00 $943.00 $583.00 $622.00 $287.00 $198.00 -------$195.00 $1,281.00 $1,214.00 $1,214.00 $1,018.00 $764.00 $126.00 $1,984.00 $659.00 $348.00 $569.00 $758.00 $203.00 $1,090.00 $914.00 $68.00 $645.00 $687.00 $183.00 $277.00 $1,441.00

-------$1,232.00 $1,678.00 $1,494.00 $2,550.00 $1,600.00 $1,759.00 $1,173.00 $286.00 $435.00 $174.00 $243.00 $1,464.00 $1,910.00 $2,447.00 $2,817.00 $3,542.00 $1,367.00 $934.00 $1,258.00 $514.00 $548.00 $579.00 $1,006.00 $624.00 $666.00 $308.00 $213.00 -------$206.00 $1,372.00 $1,292.00 $1,293.00 $1,083.00 $811.00 $135.00 $2,120.00 $703.00 $373.00 $609.00 $810.00 $217.00 $1,162.00 $976.00 $72.00 $693.00 $737.00 $196.00 $297.00 $1,537.00

-------$1,344.00 $1,836.00 $1,631.00 $2,788.00 $1,747.00 $1,920.00 $1,277.00 $292.00 $443.00 $191.00 $249.00 $1,477.00 $2,081.00 $2,670.00 $3,080.00 $3,860.00 $1,438.00 $1,015.00 $1,366.00 $555.00 $594.00 $624.00 $1,087.00 $680.00 $727.00 $340.00 $236.00 -------$214.00 $1,500.00 $1,310.00 $1,310.00 $1,104.00 $826.00 $149.00 $2,143.00 $758.00 $410.00 $664.00 $817.00 $220.00 $1,259.00 $1,064.00 $77.00 $758.00 $808.00 $217.00 $322.00 $1,556.00

-------$1,151.00 $1,567.00 $1,397.00 $2,382.00 $1,494.00 $1,645.00 $1,097.00 $109.00 $159.00 $163.00 $125.00 $181.00 $1,787.00 $2,289.00 $2,632.00 $3,315.00 $1,302.00 $872.00 $1,176.00 $482.00 $512.00 $544.00 $943.00 $583.00 $622.00 $287.00 $198.00 -------$139.00 $1,281.00 $311.00 $311.00 $335.00 $289.00 $126.00 $321.00 $659.00 $348.00 $569.00 $106.00 $56.00 $1,090.00 $914.00 $68.00 $645.00 $687.00 $183.00 $277.00 $325.00

-------$1,232.00 $1,678.00 $1,494.00 $2,550.00 $1,600.00 $1,759.00 $1,173.00 $115.00 $166.00 $174.00 $131.00 $189.00 $1,910.00 $2,447.00 $2,817.00 $3,542.00 $1,367.00 $934.00 $1,258.00 $514.00 $548.00 $579.00 $1,006.00 $624.00 $666.00 $308.00 $213.00 -------$145.00 $1,372.00 $323.00 $323.00 $350.00 $302.00 $135.00 $336.00 $703.00 $373.00 $609.00 $110.00 $59.00 $1,162.00 $976.00 $72.00 $693.00 $737.00 $196.00 $297.00 $339.00

-------$1,344.00 $1,836.00 $1,631.00 $2,788.00 $1,747.00 $1,920.00 $1,277.00 $121.00 $173.00 $191.00 $137.00 $198.00 $2,081.00 $2,670.00 $3,080.00 $3,860.00 $1,438.00 $1,015.00 $1,366.00 $555.00 $594.00 $624.00 $1,087.00 $680.00 $727.00 $340.00 $236.00 -------$154.00 $1,500.00 $338.00 $338.00 $368.00 $315.00 $149.00 $353.00 $758.00 $410.00 $664.00 $115.00 $61.00 $1,259.00 $1,064.00 $77.00 $758.00 $808.00 $217.00 $322.00 $355.00


Part B, 240



10 10 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 YYY 90 90 90

--------------------------------------------------------$510.00 $636.00 $631.00 $730.00 $584.00 $668.00 $557.00 $598.00 $621.00 $715.00 $734.00 $856.00 $754.00 $881.00 $339.00 $411.00 $491.00 $444.00 $501.00 $585.00 $774.00 $1,648.00 $1,416.00 $784.00 $770.00 $484.00 $621.00 ------------------------------------------BR $512.00 $1,394.00 $454.00 BR BR $886.00 $1,084.00 $910.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,627.00 $1,340.00 $1,383.00 $920.00 $1,005.00 $1,244.00 $1,010.00 $225.00 $775.00 $872.00 $943.00 $1,069.00 $853.00 $1,001.00 $857.00 $941.00 $891.00 $1,081.00 $1,101.00 $1,392.00 $1,146.00 $1,405.00 $404.00 $617.00 $767.00 $660.00 $706.00 $852.00 $1,042.00 $7,465.00 $1,671.00 $1,029.00 $904.00 $636.00 $827.00 $1,111.00 $1,387.00 $1,264.00 $1,544.00 $1,375.00 $1,978.00 -------$1,209.00 $2,114.00 $532.00 --------------$1,086.00 $1,481.00 $1,348.00

$1,738.00 $1,429.00 $1,477.00 $984.00 $1,075.00 $1,329.00 $1,082.00 $240.00 $831.00 $935.00 $1,011.00 $1,147.00 $915.00 $1,072.00 $919.00 $1,009.00 $956.00 $1,160.00 $1,180.00 $1,493.00 $1,228.00 $1,506.00 $433.00 $661.00 $823.00 $707.00 $757.00 $914.00 $1,110.00 $8,014.00 $1,788.00 $1,105.00 $970.00 $682.00 $887.00 $1,192.00 $1,487.00 $1,356.00 $1,656.00 $1,474.00 $2,121.00 -------$1,295.00 $2,258.00 $568.00 --------------$1,152.00 $1,555.00 $1,413.00

$1,765.00 $1,446.00 $1,492.00 $992.00 $1,085.00 $1,342.00 $1,089.00 $243.00 $904.00 $1,019.00 $1,104.00 $1,254.00 $997.00 $1,169.00 $1,002.00 $1,101.00 $1,044.00 $1,268.00 $1,289.00 $1,634.00 $1,341.00 $1,649.00 $478.00 $717.00 $896.00 $768.00 $823.00 $996.00 $1,199.00 $8,845.00 $1,953.00 $1,209.00 $1,060.00 $741.00 $964.00 $1,302.00 $1,625.00 $1,483.00 $1,812.00 $1,613.00 $2,324.00 -------$1,405.00 $2,443.00 $622.00 --------------$1,235.00 $1,638.00 $1,487.00

$379.00 $324.00 $239.00 $99.00 $134.00 $206.00 $71.00 $45.00 $775.00 $872.00 $943.00 $1,069.00 $853.00 $1,001.00 $857.00 $941.00 $891.00 $1,081.00 $1,101.00 $1,392.00 $1,146.00 $1,405.00 $404.00 $617.00 $767.00 $660.00 $706.00 $852.00 $1,042.00 $7,465.00 $1,671.00 $1,029.00 $904.00 $636.00 $827.00 $1,111.00 $1,387.00 $1,264.00 $1,544.00 $1,375.00 $1,978.00 -------$1,209.00 $2,114.00 $532.00 --------------$1,086.00 $1,481.00 $1,348.00

$398.00 $338.00 $249.00 $103.00 $140.00 $214.00 $74.00 $47.00 $831.00 $935.00 $1,011.00 $1,147.00 $915.00 $1,072.00 $919.00 $1,009.00 $956.00 $1,160.00 $1,180.00 $1,493.00 $1,228.00 $1,506.00 $433.00 $661.00 $823.00 $707.00 $757.00 $914.00 $1,110.00 $8,014.00 $1,788.00 $1,105.00 $970.00 $682.00 $887.00 $1,192.00 $1,487.00 $1,356.00 $1,656.00 $1,474.00 $2,121.00 -------$1,295.00 $2,258.00 $568.00 --------------$1,152.00 $1,555.00 $1,413.00

$422.00 $353.00 $261.00 $108.00 $147.00 $224.00 $78.00 $49.00 $904.00 $1,019.00 $1,104.00 $1,254.00 $997.00 $1,169.00 $1,002.00 $1,101.00 $1,044.00 $1,268.00 $1,289.00 $1,634.00 $1,341.00 $1,649.00 $478.00 $717.00 $896.00 $768.00 $823.00 $996.00 $1,199.00 $8,845.00 $1,953.00 $1,209.00 $1,060.00 $741.00 $964.00 $1,302.00 $1,625.00 $1,483.00 $1,812.00 $1,613.00 $2,324.00 -------$1,405.00 $2,443.00 $622.00 --------------$1,235.00 $1,638.00 $1,487.00


Part B, 241



90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 0 0 0 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 90 90 0 0 0 0 0 0

$1,137.00 $1,394.00 $1,514.00 $1,476.00 $1,839.00 $1,186.00 $1,635.00 $1,250.00 $1,180.00 $1,228.00 $1,301.00 $1,506.00 $151.00 $807.00 $1,316.00 $1,554.00 $1,695.00 $1,671.00 $1,873.00 $1,679.00 -------$1,170.00 $1,080.00 $1,680.00 ---------------------$1,083.00 $2,475.00 $2,941.00 $1,128.00 $1,507.00 ------------------------------------------$118.00 -------$203.00 $101.00 $1,441.00 $1,802.00 -------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,408.00 $1,666.00 $1,761.00 $1,727.00 $2,124.00 $1,266.00 $1,860.00 $1,554.00 $1,382.00 $1,507.00 $1,503.00 $1,664.00 $852.00 $1,122.00 $1,533.00 $1,760.00 $1,872.00 $1,898.00 $2,140.00 $1,930.00 $1,772.00 $1,391.00 $1,307.00 $2,149.00 $327.00 $287.00 $267.00 $1,389.00 $3,617.00 $4,216.00 $1,784.00 $2,958.00 $1,647.00 $1,316.00 $1,581.00 $1,033.00 $753.00 $411.00 $142.00 $175.00 $261.00 $171.00 $1,690.00 $2,037.00 $724.00 $226.00 $1,171.00 $1,575.00 $1,246.00 $653.00

$1,486.00 $1,748.00 $1,846.00 $1,810.00 $2,226.00 $1,328.00 $1,949.00 $1,646.00 $1,449.00 $1,589.00 $1,576.00 $1,750.00 $908.00 $1,200.00 $1,616.00 $1,851.00 $1,964.00 $1,991.00 $2,244.00 $2,024.00 $1,857.00 $1,462.00 $1,371.00 $2,298.00 $350.00 $307.00 $285.00 $1,488.00 $3,875.00 $4,509.00 $1,909.00 $3,175.00 $1,755.00 $1,401.00 $1,687.00 $1,101.00 $804.00 $438.00 $147.00 $184.00 $273.00 $179.00 $1,773.00 $2,136.00 $770.00 $240.00 $1,247.00 $1,678.00 $1,328.00 $696.00

$1,579.00 $1,843.00 $1,944.00 $1,906.00 $2,345.00 $1,397.00 $2,053.00 $1,757.00 $1,525.00 $1,685.00 $1,658.00 $1,854.00 $920.00 $1,307.00 $1,718.00 $1,961.00 $2,075.00 $2,101.00 $2,366.00 $2,134.00 $1,954.00 $1,543.00 $1,442.00 $2,489.00 $385.00 $338.00 $311.00 $1,615.00 $4,235.00 $4,905.00 $2,076.00 $3,463.00 $1,778.00 $1,422.00 $1,709.00 $1,118.00 $812.00 $443.00 $154.00 $192.00 $285.00 $186.00 $1,871.00 $2,251.00 $783.00 $244.00 $1,264.00 $1,700.00 $1,345.00 $704.00

$1,408.00 $1,666.00 $1,761.00 $1,727.00 $2,124.00 $1,266.00 $1,860.00 $1,554.00 $1,382.00 $1,507.00 $1,503.00 $1,664.00 $208.00 $1,122.00 $1,533.00 $1,760.00 $1,872.00 $1,898.00 $2,140.00 $1,930.00 $1,772.00 $1,391.00 $1,307.00 $2,149.00 $327.00 $287.00 $267.00 $1,389.00 $3,617.00 $4,216.00 $1,784.00 $2,958.00 $397.00 $361.00 $340.00 $258.00 $143.00 $80.00 $142.00 $143.00 $261.00 $171.00 $1,690.00 $2,037.00 $244.00 $96.00 $323.00 $399.00 $306.00 $148.00

$1,486.00 $1,748.00 $1,846.00 $1,810.00 $2,226.00 $1,328.00 $1,949.00 $1,646.00 $1,449.00 $1,589.00 $1,576.00 $1,750.00 $217.00 $1,200.00 $1,616.00 $1,851.00 $1,964.00 $1,991.00 $2,244.00 $2,024.00 $1,857.00 $1,462.00 $1,371.00 $2,298.00 $350.00 $307.00 $285.00 $1,488.00 $3,875.00 $4,509.00 $1,909.00 $3,175.00 $414.00 $376.00 $355.00 $271.00 $148.00 $83.00 $147.00 $150.00 $273.00 $179.00 $1,773.00 $2,136.00 $255.00 $101.00 $337.00 $416.00 $319.00 $155.00

$1,579.00 $1,843.00 $1,944.00 $1,906.00 $2,345.00 $1,397.00 $2,053.00 $1,757.00 $1,525.00 $1,685.00 $1,658.00 $1,854.00 $227.00 $1,307.00 $1,718.00 $1,961.00 $2,075.00 $2,101.00 $2,366.00 $2,134.00 $1,954.00 $1,543.00 $1,442.00 $2,489.00 $385.00 $338.00 $311.00 $1,615.00 $4,235.00 $4,905.00 $2,076.00 $3,463.00 $433.00 $394.00 $373.00 $285.00 $155.00 $87.00 $154.00 $157.00 $285.00 $186.00 $1,871.00 $2,251.00 $266.00 $105.00 $351.00 $434.00 $333.00 $161.00


Part B, 242



90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 90 0 0 0 0 0 0 90 10 10 90 90 ZZZ 90 90 90 90 90 0 0 10 0 0 0 0 90 ZZZ ZZZ 90 90 90

$1,471.00 $1,281.00 $1,644.00 $1,639.00 $1,468.00 $1,037.00 $1,093.00 $1,374.00 $1,428.00 $1,273.00 $1,325.00 $1,702.00 $1,555.00 BR $411.00 $447.00 $668.00 $676.00 $755.00 $580.00 $549.00 $728.00 $762.00 $991.00 $801.00 $726.00 $980.00 --------------$1,150.00 $1,054.00 -------$1,209.00 $1,152.00 $1,170.00 $1,297.00 $1,426.00 $74.00 $109.00 $89.00 $85.00 ---------------------$1,192.00 --------------$1,397.00 $1,211.00 $1,371.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,905.00 $1,676.00 $2,113.00 $2,174.00 $1,686.00 $1,340.00 $1,700.00 $2,167.00 $1,816.00 $1,955.00 $1,757.00 $2,392.00 $1,967.00 -------$518.00 $550.00 $592.00 $604.00 $686.00 $848.00 $720.00 $779.00 $828.00 $1,046.00 $828.00 $892.00 $1,027.00 $3,505.00 $6,378.00 $1,378.00 $1,457.00 $735.00 $1,428.00 $1,322.00 $1,298.00 $1,509.00 $1,677.00 $148.00 $202.00 $115.00 $140.00 $1,463.00 $1,615.00 $1,970.00 $1,358.00 $2,348.00 $1,060.00 $1,802.00 $1,487.00 $1,652.00

$2,041.00 $1,789.00 $2,247.00 $2,291.00 $1,774.00 $1,406.00 $1,783.00 $2,272.00 $1,902.00 $2,050.00 $1,845.00 $2,554.00 $2,062.00 -------$545.00 $578.00 $622.00 $636.00 $722.00 $889.00 $754.00 $815.00 $867.00 $1,095.00 $867.00 $934.00 $1,083.00 $3,745.00 $6,822.00 $1,448.00 $1,550.00 $783.00 $1,503.00 $1,388.00 $1,362.00 $1,584.00 $1,761.00 $158.00 $214.00 $121.00 $147.00 $1,560.00 $1,720.00 $2,098.00 $1,426.00 $2,512.00 $1,129.00 $1,916.00 $1,562.00 $1,740.00

$2,233.00 $1,942.00 $2,427.00 $2,432.00 $1,884.00 $1,481.00 $1,878.00 $2,392.00 $2,004.00 $2,162.00 $1,950.00 $2,771.00 $2,175.00 -------$569.00 $603.00 $651.00 $665.00 $755.00 $937.00 $795.00 $861.00 $915.00 $1,156.00 $917.00 $987.00 $1,126.00 $3,779.00 $6,872.00 $1,531.00 $1,675.00 $798.00 $1,593.00 $1,463.00 $1,434.00 $1,669.00 $1,859.00 $161.00 $221.00 $125.00 $152.00 $1,579.00 $1,743.00 $2,127.00 $1,504.00 $2,537.00 $1,146.00 $2,068.00 $1,646.00 $1,849.00

$1,905.00 $1,676.00 $2,113.00 $2,174.00 $1,686.00 $1,340.00 $1,700.00 $2,167.00 $1,816.00 $1,955.00 $1,757.00 $2,392.00 $1,967.00 -------$431.00 $455.00 $497.00 $507.00 $578.00 $848.00 $720.00 $779.00 $828.00 $1,046.00 $828.00 $892.00 $824.00 $528.00 $700.00 $1,378.00 $1,457.00 $232.00 $1,428.00 $1,322.00 $1,298.00 $1,509.00 $1,677.00 $73.00 $128.00 $115.00 $102.00 $320.00 $413.00 $525.00 $1,358.00 $297.00 $275.00 $1,802.00 $1,487.00 $1,652.00

$2,041.00 $1,789.00 $2,247.00 $2,291.00 $1,774.00 $1,406.00 $1,783.00 $2,272.00 $1,902.00 $2,050.00 $1,845.00 $2,554.00 $2,062.00 -------$451.00 $476.00 $521.00 $531.00 $606.00 $889.00 $754.00 $815.00 $867.00 $1,095.00 $867.00 $934.00 $865.00 $551.00 $731.00 $1,448.00 $1,550.00 $243.00 $1,503.00 $1,388.00 $1,362.00 $1,584.00 $1,761.00 $76.00 $135.00 $121.00 $107.00 $333.00 $431.00 $547.00 $1,426.00 $312.00 $287.00 $1,916.00 $1,562.00 $1,740.00

$2,233.00 $1,942.00 $2,427.00 $2,432.00 $1,884.00 $1,481.00 $1,878.00 $2,392.00 $2,004.00 $2,162.00 $1,950.00 $2,771.00 $2,175.00 -------$476.00 $501.00 $549.00 $560.00 $639.00 $937.00 $795.00 $861.00 $915.00 $1,156.00 $917.00 $987.00 $908.00 $575.00 $763.00 $1,531.00 $1,675.00 $256.00 $1,593.00 $1,463.00 $1,434.00 $1,669.00 $1,859.00 $80.00 $141.00 $125.00 $111.00 $348.00 $450.00 $571.00 $1,504.00 $330.00 $301.00 $2,068.00 $1,646.00 $1,849.00


Part B, 243



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 0 0 0 90 90

$640.00 $924.00 $1,386.00 $1,457.00 $1,389.00 $1,485.00 $1,391.00 $1,465.00 $1,515.00 $1,548.00 $1,226.00 $1,527.00 $1,643.00 $1,729.00 $2,351.00 $2,292.00 $1,493.00 $1,513.00 $1,163.00 $1,043.00 $1,075.00 $1,380.00 $1,107.00 $1,096.00 $1,384.00 $1,265.00 BR $414.00 $461.00 $546.00 $546.00 $510.00 $510.00 $408.00 $661.00 $641.00 $443.00 $587.00 $538.00 $439.00 $548.00 $596.00 $768.00 $704.00 $510.00 ---------------------$775.00 $764.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$736.00 $1,018.00 $1,834.00 $1,680.00 $1,659.00 $1,680.00 $1,621.00 $1,572.00 $1,653.00 $1,771.00 $1,346.00 $1,842.00 $1,784.00 $1,920.00 $2,420.00 $2,646.00 $1,795.00 $1,820.00 $1,376.00 $1,259.00 $1,283.00 $1,746.00 $1,289.00 $1,417.00 $2,029.00 $1,863.00 -------$541.00 $571.00 $612.00 $618.00 $557.00 $545.00 $531.00 $693.00 $681.00 $518.00 $680.00 $688.00 $417.00 $716.00 $684.00 $846.00 $839.00 $594.00 $87.00 $174.00 $321.00 $928.00 $870.00

$774.00 $1,069.00 $1,969.00 $1,761.00 $1,752.00 $1,763.00 $1,707.00 $1,678.00 $1,735.00 $1,859.00 $1,414.00 $1,938.00 $1,872.00 $2,016.00 $2,539.00 $2,776.00 $1,883.00 $1,909.00 $1,442.00 $1,328.00 $1,344.00 $1,862.00 $1,351.00 $1,484.00 $2,128.00 $1,953.00 -------$569.00 $600.00 $644.00 $650.00 $585.00 $570.00 $558.00 $725.00 $713.00 $543.00 $714.00 $722.00 $439.00 $757.00 $719.00 $888.00 $881.00 $624.00 $92.00 $185.00 $339.00 $975.00 $915.00

$815.00 $1,123.00 $2,161.00 $1,854.00 $1,869.00 $1,860.00 $1,810.00 $1,840.00 $1,833.00 $1,963.00 $1,491.00 $2,051.00 $1,972.00 $2,130.00 $2,682.00 $2,932.00 $1,984.00 $2,009.00 $1,517.00 $1,411.00 $1,410.00 $2,021.00 $1,418.00 $1,562.00 $2,246.00 $2,059.00 -------$594.00 $627.00 $674.00 $679.00 $612.00 $602.00 $592.00 $766.00 $752.00 $572.00 $749.00 $755.00 $460.00 $804.00 $754.00 $931.00 $925.00 $655.00 $95.00 $190.00 $351.00 $1,026.00 $964.00

$736.00 $1,018.00 $1,834.00 $1,680.00 $1,659.00 $1,680.00 $1,621.00 $1,572.00 $1,653.00 $1,771.00 $1,346.00 $1,842.00 $1,784.00 $1,920.00 $2,420.00 $2,646.00 $1,795.00 $1,820.00 $1,376.00 $1,259.00 $1,283.00 $1,746.00 $1,289.00 $1,417.00 $2,029.00 $1,863.00 -------$449.00 $475.00 $516.00 $519.00 $464.00 $545.00 $531.00 $693.00 $681.00 $518.00 $680.00 $688.00 $417.00 $716.00 $684.00 $846.00 $839.00 $594.00 $58.00 $76.00 $211.00 $928.00 $870.00

$774.00 $1,069.00 $1,969.00 $1,761.00 $1,752.00 $1,763.00 $1,707.00 $1,678.00 $1,735.00 $1,859.00 $1,414.00 $1,938.00 $1,872.00 $2,016.00 $2,539.00 $2,776.00 $1,883.00 $1,909.00 $1,442.00 $1,328.00 $1,344.00 $1,862.00 $1,351.00 $1,484.00 $2,128.00 $1,953.00 -------$470.00 $498.00 $540.00 $543.00 $486.00 $570.00 $558.00 $725.00 $713.00 $543.00 $714.00 $722.00 $439.00 $757.00 $719.00 $888.00 $881.00 $624.00 $60.00 $80.00 $221.00 $975.00 $915.00

$815.00 $1,123.00 $2,161.00 $1,854.00 $1,869.00 $1,860.00 $1,810.00 $1,840.00 $1,833.00 $1,963.00 $1,491.00 $2,051.00 $1,972.00 $2,130.00 $2,682.00 $2,932.00 $1,984.00 $2,009.00 $1,517.00 $1,411.00 $1,410.00 $2,021.00 $1,418.00 $1,562.00 $2,246.00 $2,059.00 -------$496.00 $525.00 $570.00 $573.00 $513.00 $602.00 $592.00 $766.00 $752.00 $572.00 $749.00 $755.00 $460.00 $804.00 $754.00 $931.00 $925.00 $655.00 $64.00 $85.00 $233.00 $1,026.00 $964.00


Part B, 244


Surgery CPT Code FUD 2003 MRA 51525 51530 51535 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700 51701 51702 51703 51705 51710 51715 51720 51725 51725-26 51725-TC 51726 51726-26 51726-TC 51727 51727-26 51727-TC 51728 51728-26 51728-TC 51729 51729-26 51729-TC 51736 51736-26 51736-TC 51741 51741-26 51741-TC 51784 51784-26 51784-TC 51785

90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

$1,069.00 $957.00 $932.00 $1,171.00 $1,514.00 $1,624.00 $1,762.00 $2,284.00 $2,252.00 $2,601.00 $2,441.00 $2,900.00 $3,063.00 $2,914.00 $54.00 $83.00 $45.00 $29.00 $58.00 $92.00 $128.00 $37.00 $119.00 $322.00 $140.00 $116.00 --------------$136.00 -----------------------------------------------------------------------------$47.00 --------------$81.00 --------------$119.00 --------------$52.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,251.00 $1,165.00 $1,133.00 $1,409.00 $1,853.00 $1,899.00 $2,158.00 $2,661.00 $2,764.00 $3,077.00 $2,826.00 $3,195.00 $3,433.00 $3,359.00 $254.00 $55.00 $150.00 $117.00 $77.00 $98.00 $183.00 $128.00 $181.00 $413.00 $155.00 $261.00 $111.00 $150.00 $364.00 $124.00 $240.00 $432.00 $155.00 $277.00 $435.00 $152.00 $284.00 $472.00 $183.00 $288.00 $22.00 $12.00 $10.00 $22.00 $12.00 $10.00 $268.00 $111.00 $156.00 $370.00

$1,313.00 $1,230.00 $1,189.00 $1,484.00 $1,948.00 $1,995.00 $2,264.00 $2,789.00 $2,896.00 $3,225.00 $2,963.00 $3,348.00 $3,597.00 $3,525.00 $271.00 $58.00 $158.00 $124.00 $81.00 $104.00 $193.00 $135.00 $192.00 $436.00 $163.00 $276.00 $115.00 $161.00 $387.00 $129.00 $258.00 $459.00 $162.00 $297.00 $462.00 $158.00 $305.00 $500.00 $191.00 $309.00 $23.00 $12.00 $11.00 $24.00 $12.00 $11.00 $284.00 $116.00 $168.00 $397.00

$1,383.00 $1,308.00 $1,250.00 $1,572.00 $2,061.00 $2,109.00 $2,391.00 $2,941.00 $3,052.00 $3,401.00 $3,128.00 $3,531.00 $3,793.00 $3,727.00 $275.00 $61.00 $162.00 $128.00 $84.00 $107.00 $200.00 $139.00 $198.00 $453.00 $170.00 $282.00 $120.00 $162.00 $394.00 $134.00 $260.00 $467.00 $169.00 $299.00 $471.00 $164.00 $306.00 $510.00 $199.00 $311.00 $24.00 $13.00 $11.00 $24.00 $13.00 $12.00 $290.00 $121.00 $169.00 $413.00

$1,251.00 $1,165.00 $1,133.00 $1,409.00 $1,853.00 $1,899.00 $2,158.00 $2,661.00 $2,764.00 $3,077.00 $2,826.00 $3,195.00 $3,433.00 $3,359.00 $65.00 $55.00 $93.00 $66.00 $41.00 $44.00 $118.00 $75.00 $116.00 $292.00 $117.00 $261.00 $111.00 $150.00 $364.00 $124.00 $240.00 $432.00 $155.00 $277.00 $435.00 $152.00 $284.00 $472.00 $183.00 $288.00 $22.00 $12.00 $10.00 $22.00 $12.00 $10.00 $268.00 $111.00 $156.00 $370.00

$1,313.00 $1,230.00 $1,189.00 $1,484.00 $1,948.00 $1,995.00 $2,264.00 $2,789.00 $2,896.00 $3,225.00 $2,963.00 $3,348.00 $3,597.00 $3,525.00 $68.00 $58.00 $97.00 $69.00 $43.00 $46.00 $124.00 $79.00 $122.00 $306.00 $122.00 $276.00 $115.00 $161.00 $387.00 $129.00 $258.00 $459.00 $162.00 $297.00 $462.00 $158.00 $305.00 $500.00 $191.00 $309.00 $23.00 $12.00 $11.00 $24.00 $12.00 $11.00 $284.00 $116.00 $168.00 $397.00

$1,383.00 $1,308.00 $1,250.00 $1,572.00 $2,061.00 $2,109.00 $2,391.00 $2,941.00 $3,052.00 $3,401.00 $3,128.00 $3,531.00 $3,793.00 $3,727.00 $71.00 $61.00 $101.00 $73.00 $45.00 $49.00 $130.00 $83.00 $128.00 $322.00 $128.00 $282.00 $120.00 $162.00 $394.00 $134.00 $260.00 $467.00 $169.00 $299.00 $471.00 $164.00 $306.00 $510.00 $199.00 $311.00 $24.00 $13.00 $11.00 $24.00 $13.00 $12.00 $290.00 $121.00 $169.00 $413.00


Part B, 245


Surgery CPT Code FUD 2003 MRA 51785-26 51785-TC 51792 51792-26 51792-TC 51797 51797-26 51797-TC 51798 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52001 52005 52007 52010 52204 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281 52282 52283 52285 52287 52290 52300

0 0 0 0 0 ZZZ ZZZ ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

--------------$143.00 --------------$109.00 --------------$20.00 $1,294.00 $1,236.00 $858.00 $1,040.00 $843.00 $912.00 $1,150.00 $590.00 $1,050.00 $881.00 $1,167.00 $2,082.00 $1,848.00 $858.00 $850.00 $925.00 $190.00 $133.00 $265.00 $230.00 $292.00 $286.00 $367.00 $339.00 $471.00 $546.00 $887.00 $311.00 $262.00 $243.00 $374.00 $446.00 $490.00 $448.00 $259.00 $560.00 $309.00 $375.00 -------$304.00 $370.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$131.00 $239.00 $292.00 $80.00 $212.00 $155.00 $58.00 $97.00 $26.00 $1,516.00 $1,628.00 $954.00 $1,134.00 $852.00 $1,091.00 $1,307.00 $682.00 $1,217.00 $1,285.00 $1,623.00 $2,425.00 $2,032.00 $1,035.00 $1,090.00 $1,223.00 $288.00 $531.00 $372.00 $616.00 $520.00 $512.00 $911.00 $955.00 $360.00 $422.00 $574.00 $351.00 $307.00 $510.00 $498.00 $672.00 $387.00 $473.00 $383.00 $493.00 $394.00 $397.00 $438.00 $357.00 $410.00

$141.00 $256.00 $311.00 $84.00 $227.00 $164.00 $61.00 $104.00 $29.00 $1,591.00 $1,718.00 $1,002.00 $1,192.00 $895.00 $1,153.00 $1,376.00 $719.00 $1,280.00 $1,380.00 $1,742.00 $2,553.00 $2,133.00 $1,086.00 $1,144.00 $1,285.00 $305.00 $560.00 $394.00 $655.00 $552.00 $545.00 $971.00 $1,017.00 $377.00 $442.00 $601.00 $368.00 $322.00 $542.00 $528.00 $712.00 $406.00 $496.00 $405.00 $516.00 $415.00 $419.00 $463.00 $374.00 $430.00

$155.00 $258.00 $317.00 $88.00 $229.00 $167.00 $63.00 $104.00 $29.00 $1,676.00 $1,830.00 $1,055.00 $1,258.00 $942.00 $1,226.00 $1,457.00 $759.00 $1,350.00 $1,508.00 $1,909.00 $2,718.00 $2,252.00 $1,141.00 $1,204.00 $1,355.00 $315.00 $584.00 $406.00 $669.00 $568.00 $557.00 $988.00 $1,036.00 $397.00 $466.00 $634.00 $388.00 $339.00 $556.00 $543.00 $733.00 $428.00 $523.00 $418.00 $545.00 $432.00 $435.00 $478.00 $394.00 $453.00

$131.00 $239.00 $292.00 $80.00 $212.00 $155.00 $58.00 $97.00 $26.00 $1,516.00 $1,628.00 $954.00 $1,134.00 $852.00 $1,091.00 $1,307.00 $682.00 $1,217.00 $1,285.00 $1,623.00 $2,425.00 $2,032.00 $1,035.00 $1,090.00 $1,223.00 $184.00 $420.00 $194.00 $242.00 $244.00 $207.00 $258.00 $299.00 $360.00 $422.00 $574.00 $351.00 $307.00 $238.00 $265.00 $363.00 $387.00 $473.00 $222.00 $493.00 $294.00 $286.00 $247.00 $357.00 $410.00

$141.00 $256.00 $311.00 $84.00 $227.00 $164.00 $61.00 $104.00 $29.00 $1,591.00 $1,718.00 $1,002.00 $1,192.00 $895.00 $1,153.00 $1,376.00 $719.00 $1,280.00 $1,380.00 $1,742.00 $2,553.00 $2,133.00 $1,086.00 $1,144.00 $1,285.00 $193.00 $440.00 $203.00 $253.00 $257.00 $217.00 $270.00 $312.00 $377.00 $442.00 $601.00 $368.00 $322.00 $249.00 $278.00 $380.00 $406.00 $496.00 $233.00 $516.00 $308.00 $300.00 $259.00 $374.00 $430.00

$155.00 $258.00 $317.00 $88.00 $229.00 $167.00 $63.00 $104.00 $29.00 $1,676.00 $1,830.00 $1,055.00 $1,258.00 $942.00 $1,226.00 $1,457.00 $759.00 $1,350.00 $1,508.00 $1,909.00 $2,718.00 $2,252.00 $1,141.00 $1,204.00 $1,355.00 $203.00 $464.00 $214.00 $267.00 $271.00 $228.00 $286.00 $330.00 $397.00 $466.00 $634.00 $388.00 $339.00 $263.00 $292.00 $401.00 $428.00 $523.00 $245.00 $545.00 $325.00 $316.00 $273.00 $394.00 $453.00


Part B, 246



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 10 90 0 90 10 90 90 0 90 90 90 90 90

$382.00 $370.00 $348.00 $553.00 $772.00 $684.00 $369.00 $494.00 $369.00 $507.00 $451.00 $340.00 $317.00 $344.00 $380.00 $407.00 $433.00 $488.00 $297.00 $349.00 $404.00 $372.00 $447.00 -------$580.00 ---------------------$602.00 $705.00 $1,021.00 $653.00 $573.00 $858.00 $957.00 -------$517.00 $224.00 $336.00 $153.00 $460.00 $180.00 $567.00 $836.00 $218.00 $904.00 $1,142.00 $546.00 $760.00 $607.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$424.00 $408.00 $344.00 $585.00 $1,121.00 $694.00 $361.00 $470.00 $384.00 $693.00 $676.00 $375.00 $416.00 $452.00 $503.00 $541.00 $578.00 $653.00 $443.00 $518.00 $574.00 $610.00 $684.00 $609.00 $696.00 $391.00 $1,710.00 $1,298.00 $681.00 $707.00 $1,231.00 $579.00 $454.00 $2,467.00 $2,542.00 $1,196.00 $639.00 $214.00 $426.00 $141.00 $568.00 $263.00 $608.00 $969.00 $226.00 $1,120.00 $1,354.00 $660.00 $879.00 $918.00

$444.00 $428.00 $364.00 $618.00 $1,190.00 $727.00 $378.00 $493.00 $402.00 $734.00 $720.00 $393.00 $435.00 $474.00 $527.00 $567.00 $605.00 $684.00 $464.00 $543.00 $601.00 $639.00 $716.00 $638.00 $730.00 $409.00 $1,826.00 $1,390.00 $715.00 $743.00 $1,291.00 $608.00 $478.00 $2,625.00 $2,704.00 $1,255.00 $671.00 $225.00 $448.00 $148.00 $596.00 $277.00 $639.00 $1,019.00 $238.00 $1,174.00 $1,420.00 $694.00 $922.00 $963.00

$468.00 $451.00 $377.00 $641.00 $1,221.00 $767.00 $398.00 $520.00 $425.00 $757.00 $734.00 $414.00 $459.00 $499.00 $556.00 $599.00 $639.00 $721.00 $489.00 $572.00 $634.00 $674.00 $756.00 $673.00 $768.00 $433.00 $1,852.00 $1,400.00 $750.00 $779.00 $1,358.00 $637.00 $499.00 $2,679.00 $2,762.00 $1,319.00 $704.00 $235.00 $468.00 $156.00 $625.00 $289.00 $669.00 $1,069.00 $250.00 $1,235.00 $1,496.00 $730.00 $969.00 $1,012.00

$424.00 $408.00 $222.00 $401.00 $509.00 $694.00 $361.00 $470.00 $384.00 $386.00 $227.00 $375.00 $416.00 $452.00 $503.00 $541.00 $578.00 $653.00 $443.00 $518.00 $574.00 $610.00 $684.00 $609.00 $696.00 $391.00 $335.00 $89.00 $681.00 $707.00 $1,231.00 $579.00 $454.00 $940.00 $1,003.00 $1,196.00 $639.00 $214.00 $426.00 $141.00 $568.00 $238.00 $608.00 $969.00 $208.00 $1,120.00 $1,354.00 $660.00 $879.00 $918.00

$444.00 $428.00 $232.00 $420.00 $533.00 $727.00 $378.00 $493.00 $402.00 $404.00 $238.00 $393.00 $435.00 $474.00 $527.00 $567.00 $605.00 $684.00 $464.00 $543.00 $601.00 $639.00 $716.00 $638.00 $730.00 $409.00 $352.00 $93.00 $715.00 $743.00 $1,291.00 $608.00 $478.00 $987.00 $1,053.00 $1,255.00 $671.00 $225.00 $448.00 $148.00 $596.00 $250.00 $639.00 $1,019.00 $218.00 $1,174.00 $1,420.00 $694.00 $922.00 $963.00

$468.00 $451.00 $245.00 $443.00 $563.00 $767.00 $398.00 $520.00 $425.00 $426.00 $251.00 $414.00 $459.00 $499.00 $556.00 $599.00 $639.00 $721.00 $489.00 $572.00 $634.00 $674.00 $756.00 $673.00 $768.00 $433.00 $373.00 $99.00 $750.00 $779.00 $1,358.00 $637.00 $499.00 $1,036.00 $1,107.00 $1,319.00 $704.00 $235.00 $468.00 $156.00 $625.00 $262.00 $669.00 $1,069.00 $230.00 $1,235.00 $1,496.00 $730.00 $969.00 $1,012.00


Part B, 247



90 90 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 0 90 YYY 10 10 10 10 10 10 10

$506.00 $464.00 $240.00 $295.00 $226.00 $332.00 $929.00 $1,088.00 $1,151.00 $1,381.00 $1,088.00 $1,150.00 $1,116.00 $1,053.00 $1,057.00 $639.00 $755.00 $1,197.00 $699.00 $991.00 $1,259.00 $784.00 $447.00 $494.00 -------$590.00 $586.00 $777.00 $987.00 $661.00 $37.00 $37.00 $81.00 $59.00 $45.00 $49.00 $50.00 $50.00 $741.00 $728.00 --------------BR $348.00 $91.00 $106.00 $100.00 $149.00 $180.00 $281.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$620.00 $602.00 $290.00 $312.00 $300.00 $381.00 $1,165.00 $1,270.00 $1,423.00 $1,646.00 $1,242.00 $1,363.00 $1,403.00 $1,688.00 $1,093.00 $1,135.00 $1,152.00 $1,092.00 $932.00 $1,174.00 $1,875.00 $887.00 $593.00 $663.00 $1,087.00 $705.00 $707.00 $917.00 $1,156.00 $807.00 $119.00 $115.00 $95.00 $165.00 $155.00 $99.00 $97.00 $57.00 $2,858.00 $2,640.00 $1,060.00 $2,116.00 -------$451.00 $186.00 $168.00 $200.00 $191.00 $253.00 $311.00

$653.00 $638.00 $305.00 $329.00 $316.00 $400.00 $1,223.00 $1,332.00 $1,492.00 $1,726.00 $1,304.00 $1,429.00 $1,472.00 $1,771.00 $1,147.00 $1,192.00 $1,208.00 $1,146.00 $979.00 $1,232.00 $1,968.00 $931.00 $623.00 $696.00 $1,141.00 $740.00 $743.00 $962.00 $1,213.00 $847.00 $125.00 $121.00 $99.00 $174.00 $164.00 $105.00 $103.00 $59.00 $3,047.00 $2,812.00 $1,134.00 $2,263.00 -------$474.00 $198.00 $178.00 $213.00 $202.00 $268.00 $329.00

$686.00 $678.00 $320.00 $343.00 $331.00 $420.00 $1,287.00 $1,401.00 $1,570.00 $1,818.00 $1,372.00 $1,504.00 $1,551.00 $1,868.00 $1,205.00 $1,251.00 $1,269.00 $1,204.00 $1,028.00 $1,295.00 $2,076.00 $978.00 $653.00 $730.00 $1,201.00 $777.00 $780.00 $1,011.00 $1,275.00 $888.00 $130.00 $126.00 $105.00 $181.00 $170.00 $108.00 $106.00 $63.00 $3,098.00 $2,865.00 $1,144.00 $2,286.00 -------$499.00 $204.00 $184.00 $220.00 $208.00 $278.00 $343.00

$620.00 $602.00 $262.00 $270.00 $270.00 $381.00 $1,165.00 $1,270.00 $1,423.00 $1,646.00 $1,242.00 $1,363.00 $1,403.00 $1,688.00 $1,093.00 $1,135.00 $1,152.00 $1,092.00 $932.00 $1,174.00 $1,875.00 $887.00 $593.00 $663.00 $1,087.00 $705.00 $707.00 $917.00 $1,156.00 $807.00 $93.00 $78.00 $95.00 $127.00 $105.00 $61.00 $59.00 $57.00 $879.00 $904.00 $121.00 $329.00 -------$451.00 $150.00 $133.00 $159.00 $136.00 $188.00 $250.00

$653.00 $638.00 $275.00 $283.00 $284.00 $400.00 $1,223.00 $1,332.00 $1,492.00 $1,726.00 $1,304.00 $1,429.00 $1,472.00 $1,771.00 $1,147.00 $1,192.00 $1,208.00 $1,146.00 $979.00 $1,232.00 $1,968.00 $931.00 $623.00 $696.00 $1,141.00 $740.00 $743.00 $962.00 $1,213.00 $847.00 $97.00 $82.00 $99.00 $133.00 $111.00 $64.00 $62.00 $59.00 $924.00 $948.00 $127.00 $346.00 -------$474.00 $159.00 $140.00 $168.00 $144.00 $198.00 $264.00

$686.00 $678.00 $290.00 $298.00 $300.00 $420.00 $1,287.00 $1,401.00 $1,570.00 $1,818.00 $1,372.00 $1,504.00 $1,551.00 $1,868.00 $1,205.00 $1,251.00 $1,269.00 $1,204.00 $1,028.00 $1,295.00 $2,076.00 $978.00 $653.00 $730.00 $1,201.00 $777.00 $780.00 $1,011.00 $1,275.00 $888.00 $102.00 $86.00 $105.00 $140.00 $116.00 $67.00 $65.00 $63.00 $968.00 $996.00 $134.00 $363.00 -------$499.00 $166.00 $147.00 $176.00 $150.00 $207.00 $277.00


Part B, 248


Surgery CPT Code FUD 2003 MRA 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54240-26 54240-TC 54250 54250-26 54250-TC 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 54332 54336 54340 54344 54348 54352 54360 54380 54385 54390 54400 54401 54405 54406 54408

0 10 90 90 90 90 90 90 90 90 10 10 10 10 90 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$149.00 $261.00 $775.00 $1,035.00 $1,210.00 $588.00 $777.00 $1,092.00 $1,532.00 $1,945.00 $220.00 $207.00 $182.00 $78.00 $633.00 $189.00 $104.00 $172.00 $81.00 $109.00 --------------$104.00 --------------$830.00 $988.00 $881.00 $1,067.00 $1,316.00 $900.00 $974.00 $1,260.00 $1,212.00 $1,201.00 $1,327.00 $1,672.00 $727.00 $1,360.00 $1,318.00 $1,820.00 $898.00 $1,054.00 $1,217.00 $1,635.00 $784.00 $892.00 $1,294.00 $687.00 $724.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$280.00 $377.00 $919.00 $1,164.00 $1,368.00 $651.00 $917.00 $1,182.00 $1,733.00 $2,182.00 $366.00 $316.00 $278.00 $151.00 $772.00 $290.00 $138.00 $201.00 $128.00 $146.00 $98.00 $48.00 $174.00 $159.00 $15.00 $930.00 $1,090.00 $1,039.00 $1,254.00 $1,531.00 $1,089.00 $1,116.00 $1,450.00 $1,376.00 $1,367.00 $1,561.00 $1,825.00 $826.00 $1,538.00 $1,475.00 $2,064.00 $1,047.00 $1,162.00 $1,423.00 $1,904.00 $769.00 $949.00 $1,176.00 $1,062.00 $1,148.00

$297.00 $397.00 $966.00 $1,221.00 $1,436.00 $685.00 $963.00 $1,241.00 $1,815.00 $2,281.00 $387.00 $332.00 $293.00 $159.00 $810.00 $307.00 $146.00 $211.00 $135.00 $154.00 $103.00 $51.00 $182.00 $165.00 $16.00 $976.00 $1,143.00 $1,090.00 $1,322.00 $1,614.00 $1,149.00 $1,168.00 $1,521.00 $1,443.00 $1,434.00 $1,645.00 $1,924.00 $868.00 $1,644.00 $1,547.00 $2,164.00 $1,098.00 $1,219.00 $1,501.00 $2,007.00 $807.00 $998.00 $1,233.00 $1,114.00 $1,204.00

$308.00 $413.00 $1,017.00 $1,284.00 $1,512.00 $717.00 $1,011.00 $1,307.00 $1,909.00 $2,392.00 $402.00 $347.00 $306.00 $164.00 $850.00 $319.00 $152.00 $221.00 $141.00 $162.00 $110.00 $52.00 $189.00 $173.00 $17.00 $1,025.00 $1,202.00 $1,145.00 $1,401.00 $1,711.00 $1,216.00 $1,225.00 $1,597.00 $1,517.00 $1,508.00 $1,742.00 $2,041.00 $910.00 $1,786.00 $1,628.00 $2,278.00 $1,154.00 $1,281.00 $1,590.00 $2,129.00 $848.00 $1,045.00 $1,296.00 $1,171.00 $1,266.00

$183.00 $309.00 $919.00 $1,164.00 $1,368.00 $615.00 $917.00 $1,182.00 $1,733.00 $2,182.00 $289.00 $316.00 $278.00 $120.00 $772.00 $196.00 $116.00 $169.00 $106.00 $146.00 $98.00 $48.00 $174.00 $159.00 $15.00 $930.00 $1,090.00 $1,039.00 $1,254.00 $1,531.00 $1,089.00 $1,116.00 $1,450.00 $1,376.00 $1,367.00 $1,561.00 $1,825.00 $826.00 $1,538.00 $1,475.00 $2,064.00 $1,047.00 $1,162.00 $1,423.00 $1,904.00 $769.00 $949.00 $1,176.00 $1,062.00 $1,148.00

$193.00 $324.00 $966.00 $1,221.00 $1,436.00 $647.00 $963.00 $1,241.00 $1,815.00 $2,281.00 $303.00 $332.00 $293.00 $126.00 $810.00 $206.00 $121.00 $177.00 $112.00 $154.00 $103.00 $51.00 $182.00 $165.00 $16.00 $976.00 $1,143.00 $1,090.00 $1,322.00 $1,614.00 $1,149.00 $1,168.00 $1,521.00 $1,443.00 $1,434.00 $1,645.00 $1,924.00 $868.00 $1,644.00 $1,547.00 $2,164.00 $1,098.00 $1,219.00 $1,501.00 $2,007.00 $807.00 $998.00 $1,233.00 $1,114.00 $1,204.00

$203.00 $340.00 $1,017.00 $1,284.00 $1,512.00 $678.00 $1,011.00 $1,307.00 $1,909.00 $2,392.00 $318.00 $347.00 $306.00 $131.00 $850.00 $218.00 $127.00 $186.00 $117.00 $162.00 $110.00 $52.00 $189.00 $173.00 $17.00 $1,025.00 $1,202.00 $1,145.00 $1,401.00 $1,711.00 $1,216.00 $1,225.00 $1,597.00 $1,517.00 $1,508.00 $1,742.00 $2,041.00 $910.00 $1,786.00 $1,628.00 $2,278.00 $1,154.00 $1,281.00 $1,590.00 $2,129.00 $848.00 $1,045.00 $1,296.00 $1,171.00 $1,266.00


Part B, 249



90 90 90 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 10 0 90 90 90 90 90 90 90 0 90 90 90 10 90 90 90 90 90

$856.00 $933.00 $510.00 $665.00 $819.00 $899.00 $799.00 $503.00 --------------BR $88.00 $102.00 $259.00 $519.00 $445.00 $589.00 $683.00 $922.00 $588.00 $842.00 $524.00 $373.00 $594.00 $861.00 $401.00 $485.00 $948.00 $825.00 $850.00 BR $133.00 $257.00 $411.00 $432.00 $503.00 $696.00 -------$969.00 $1,340.00 $109.00 $439.00 $634.00 $430.00 $156.00 $223.00 $350.00 $562.00 $426.00 $796.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,249.00 $1,491.00 $766.00 $1,029.00 $1,306.00 $1,024.00 $929.00 $602.00 $991.00 $2,008.00 -------$101.00 $108.00 $305.00 $784.00 $473.00 $908.00 $733.00 $1,081.00 $716.00 $998.00 $661.00 $438.00 $696.00 $1,030.00 $517.00 $585.00 $1,152.00 $1,098.00 $1,274.00 -------$311.00 $186.00 $540.00 $465.00 $607.00 $822.00 $519.00 $1,227.00 $1,620.00 $167.00 $490.00 $739.00 $552.00 $307.00 $562.00 $517.00 $714.00 $524.00 $1,006.00

$1,310.00 $1,563.00 $804.00 $1,081.00 $1,369.00 $1,074.00 $975.00 $632.00 $1,043.00 $2,116.00 -------$106.00 $113.00 $320.00 $824.00 $498.00 $963.00 $771.00 $1,133.00 $753.00 $1,047.00 $694.00 $460.00 $733.00 $1,080.00 $543.00 $615.00 $1,209.00 $1,177.00 $1,368.00 -------$328.00 $195.00 $568.00 $489.00 $637.00 $863.00 $545.00 $1,294.00 $1,708.00 $176.00 $516.00 $777.00 $581.00 $325.00 $592.00 $544.00 $751.00 $551.00 $1,058.00

$1,377.00 $1,643.00 $844.00 $1,134.00 $1,439.00 $1,129.00 $1,024.00 $662.00 $1,099.00 $2,248.00 -------$111.00 $119.00 $335.00 $867.00 $525.00 $1,029.00 $809.00 $1,191.00 $791.00 $1,101.00 $728.00 $483.00 $772.00 $1,132.00 $569.00 $643.00 $1,271.00 $1,285.00 $1,499.00 -------$346.00 $206.00 $596.00 $513.00 $668.00 $905.00 $571.00 $1,371.00 $1,811.00 $183.00 $542.00 $816.00 $610.00 $338.00 $622.00 $571.00 $790.00 $578.00 $1,113.00

$1,249.00 $1,491.00 $766.00 $1,029.00 $1,306.00 $1,024.00 $929.00 $602.00 $991.00 $2,008.00 -------$84.00 $108.00 $305.00 $784.00 $473.00 $908.00 $733.00 $1,081.00 $716.00 $998.00 $661.00 $438.00 $696.00 $1,030.00 $517.00 $585.00 $1,152.00 $1,098.00 $1,274.00 -------$311.00 $186.00 $540.00 $465.00 $607.00 $822.00 $519.00 $1,227.00 $1,620.00 $124.00 $490.00 $739.00 $552.00 $241.00 $562.00 $517.00 $714.00 $524.00 $1,006.00

$1,310.00 $1,563.00 $804.00 $1,081.00 $1,369.00 $1,074.00 $975.00 $632.00 $1,043.00 $2,116.00 -------$88.00 $113.00 $320.00 $824.00 $498.00 $963.00 $771.00 $1,133.00 $753.00 $1,047.00 $694.00 $460.00 $733.00 $1,080.00 $543.00 $615.00 $1,209.00 $1,177.00 $1,368.00 -------$328.00 $195.00 $568.00 $489.00 $637.00 $863.00 $545.00 $1,294.00 $1,708.00 $130.00 $516.00 $777.00 $581.00 $254.00 $592.00 $544.00 $751.00 $551.00 $1,058.00

$1,377.00 $1,643.00 $844.00 $1,134.00 $1,439.00 $1,129.00 $1,024.00 $662.00 $1,099.00 $2,248.00 -------$94.00 $119.00 $335.00 $867.00 $525.00 $1,029.00 $809.00 $1,191.00 $791.00 $1,101.00 $728.00 $483.00 $772.00 $1,132.00 $569.00 $643.00 $1,271.00 $1,285.00 $1,499.00 -------$346.00 $206.00 $596.00 $513.00 $668.00 $905.00 $571.00 $1,371.00 $1,811.00 $137.00 $542.00 $816.00 $610.00 $267.00 $622.00 $571.00 $790.00 $578.00 $1,113.00


Part B, 250



90 90 0 90 10 90 90 90 90 90 90 YYY 90 90 90 90 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 0 YYY 0 10 10 10 10 0 10 10 0 ZZZ 90

$310.00 $349.00 $167.00 $660.00 $391.00 $445.00 $446.00 $467.00 $496.00 $572.00 $486.00 BR $486.00 $609.00 $853.00 $426.00 $183.00 $368.00 -------$555.00 $670.00 $1,331.00 $1,711.00 $1,989.00 $2,328.00 $1,153.00 $1,252.00 $1,705.00 $1,859.00 $2,222.00 $1,012.00 $1,351.00 $1,890.00 $1,615.00 $166.00 $1,127.00 --------------BR -------$131.00 $130.00 $271.00 $183.00 -------$122.00 $200.00 $96.00 $49.00 $607.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$614.00 $539.00 $273.00 $744.00 $509.00 $578.00 $669.00 $509.00 $623.00 $802.00 $623.00 -------$611.00 $798.00 $1,045.00 $515.00 $308.00 $387.00 $542.00 $657.00 $860.00 $1,605.00 $1,927.00 $2,346.00 $2,586.00 $1,272.00 $1,377.00 $1,707.00 $1,706.00 $1,989.00 $1,274.00 $1,683.00 $1,944.00 $2,024.00 $251.00 $9,706.00 $1,107.00 $192.00 -------$651.00 $155.00 $172.00 $261.00 $205.00 $68.00 $185.00 $323.00 $117.00 $54.00 $755.00

$650.00 $571.00 $286.00 $785.00 $537.00 $612.00 $717.00 $536.00 $655.00 $858.00 $654.00 -------$641.00 $842.00 $1,096.00 $543.00 $326.00 $406.00 $569.00 $690.00 $903.00 $1,686.00 $2,023.00 $2,459.00 $2,712.00 $1,334.00 $1,443.00 $1,791.00 $1,789.00 $2,085.00 $1,336.00 $1,774.00 $2,037.00 $2,130.00 $265.00 $10,388.00 $1,161.00 $203.00 -------$680.00 $164.00 $182.00 $275.00 $216.00 $72.00 $196.00 $342.00 $123.00 $57.00 $804.00

$671.00 $587.00 $302.00 $832.00 $557.00 $649.00 $776.00 $562.00 $687.00 $930.00 $686.00 -------$672.00 $890.00 $1,153.00 $570.00 $337.00 $426.00 $597.00 $724.00 $948.00 $1,780.00 $2,137.00 $2,590.00 $2,864.00 $1,404.00 $1,519.00 $1,886.00 $1,883.00 $2,197.00 $1,406.00 $1,882.00 $2,145.00 $2,224.00 $276.00 $10,478.00 $1,217.00 $210.00 -------$712.00 $171.00 $189.00 $289.00 $225.00 $75.00 $204.00 $359.00 $129.00 $60.00 $858.00

$403.00 $327.00 $273.00 $744.00 $373.00 $578.00 $669.00 $509.00 $623.00 $802.00 $623.00 -------$611.00 $798.00 $1,045.00 $515.00 $203.00 $387.00 $542.00 $657.00 $860.00 $1,605.00 $1,927.00 $2,346.00 $2,586.00 $1,272.00 $1,377.00 $1,707.00 $1,706.00 $1,989.00 $1,274.00 $1,683.00 $1,944.00 $2,024.00 $208.00 $1,118.00 $1,107.00 $146.00 -------$651.00 $154.00 $131.00 $261.00 $197.00 $68.00 $164.00 $290.00 $87.00 $43.00 $755.00

$424.00 $345.00 $286.00 $785.00 $392.00 $612.00 $717.00 $536.00 $655.00 $858.00 $654.00 -------$641.00 $842.00 $1,096.00 $543.00 $213.00 $406.00 $569.00 $690.00 $903.00 $1,686.00 $2,023.00 $2,459.00 $2,712.00 $1,334.00 $1,443.00 $1,791.00 $1,789.00 $2,085.00 $1,336.00 $1,774.00 $2,037.00 $2,130.00 $218.00 $1,174.00 $1,161.00 $153.00 -------$680.00 $163.00 $138.00 $275.00 $208.00 $72.00 $173.00 $306.00 $92.00 $46.00 $804.00

$444.00 $360.00 $302.00 $832.00 $411.00 $649.00 $776.00 $562.00 $687.00 $930.00 $686.00 -------$672.00 $890.00 $1,153.00 $570.00 $225.00 $426.00 $597.00 $724.00 $948.00 $1,780.00 $2,137.00 $2,590.00 $2,864.00 $1,404.00 $1,519.00 $1,886.00 $1,883.00 $2,197.00 $1,406.00 $1,882.00 $2,145.00 $2,224.00 $229.00 $1,236.00 $1,217.00 $160.00 -------$712.00 $170.00 $145.00 $289.00 $218.00 $75.00 $181.00 $324.00 $97.00 $49.00 $858.00


Part B, 251



90 90 90 90 90 90 90 90 10 10 10 90 10 0 0 10 90 0 10 10 10 10 0 10 90 90 90 90 90 90 90 10 10 0 0 0 0 0 10 90 90 90 90 90 90 90 90 ZZZ 90 90

$735.00 $1,061.00 $1,400.00 $1,636.00 $1,350.00 $1,537.00 $1,806.00 $1,777.00 $227.00 $321.00 $310.00 $1,349.00 $316.00 $119.00 $154.00 $237.00 $429.00 $118.00 $179.00 $290.00 $124.00 $251.00 $90.00 $132.00 $409.00 $1,467.00 $1,787.00 $1,015.00 $1,793.00 $1,907.00 $612.00 $220.00 $231.00 $50.00 $383.00 -------$67.00 $74.00 $124.00 $313.00 $395.00 $378.00 $442.00 $536.00 $485.00 $700.00 $902.00 -------$577.00 $867.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$919.00 $1,365.00 $1,747.00 $2,025.00 $1,790.00 $1,943.00 $2,231.00 $2,253.00 $266.00 $434.00 $346.00 $1,685.00 $374.00 $161.00 $212.00 $269.00 $620.00 $133.00 $243.00 $444.00 $161.00 $279.00 $127.00 $194.00 $716.00 $2,134.00 $2,573.00 $1,283.00 $2,325.00 $2,745.00 $729.00 $251.00 $274.00 $63.00 $609.00 $279.00 $107.00 $87.00 $198.00 $434.00 $526.00 $455.00 $565.00 $964.00 $969.00 $1,196.00 $1,310.00 $371.00 $693.00 $1,153.00

$980.00 $1,457.00 $1,867.00 $2,162.00 $1,912.00 $2,086.00 $2,384.00 $2,413.00 $280.00 $459.00 $364.00 $1,780.00 $394.00 $171.00 $224.00 $283.00 $653.00 $140.00 $256.00 $467.00 $170.00 $296.00 $135.00 $206.00 $760.00 $2,269.00 $2,757.00 $1,348.00 $2,447.00 $2,938.00 $767.00 $264.00 $289.00 $67.00 $641.00 $293.00 $113.00 $91.00 $209.00 $459.00 $554.00 $479.00 $594.00 $1,013.00 $1,019.00 $1,256.00 $1,376.00 $389.00 $730.00 $1,214.00

$1,054.00 $1,577.00 $2,026.00 $2,339.00 $2,075.00 $2,284.00 $2,592.00 $2,635.00 $293.00 $487.00 $384.00 $1,896.00 $415.00 $180.00 $236.00 $297.00 $686.00 $147.00 $270.00 $491.00 $177.00 $312.00 $142.00 $216.00 $809.00 $2,448.00 $3,016.00 $1,421.00 $2,591.00 $3,208.00 $806.00 $276.00 $304.00 $69.00 $660.00 $301.00 $117.00 $96.00 $217.00 $484.00 $583.00 $502.00 $625.00 $1,066.00 $1,073.00 $1,324.00 $1,450.00 $411.00 $769.00 $1,285.00

$919.00 $1,365.00 $1,747.00 $2,025.00 $1,790.00 $1,943.00 $2,231.00 $2,253.00 $266.00 $434.00 $346.00 $1,685.00 $374.00 $127.00 $168.00 $269.00 $620.00 $117.00 $243.00 $444.00 $140.00 $252.00 $98.00 $181.00 $716.00 $2,134.00 $2,573.00 $1,283.00 $2,325.00 $2,745.00 $729.00 $227.00 $249.00 $42.00 $420.00 $211.00 $68.00 $70.00 $151.00 $434.00 $526.00 $455.00 $565.00 $964.00 $969.00 $1,196.00 $1,310.00 $371.00 $693.00 $1,153.00

$980.00 $1,457.00 $1,867.00 $2,162.00 $1,912.00 $2,086.00 $2,384.00 $2,413.00 $280.00 $459.00 $364.00 $1,780.00 $394.00 $134.00 $178.00 $283.00 $653.00 $123.00 $256.00 $467.00 $148.00 $267.00 $103.00 $192.00 $760.00 $2,269.00 $2,757.00 $1,348.00 $2,447.00 $2,938.00 $767.00 $239.00 $262.00 $44.00 $438.00 $219.00 $71.00 $74.00 $159.00 $459.00 $554.00 $479.00 $594.00 $1,013.00 $1,019.00 $1,256.00 $1,376.00 $389.00 $730.00 $1,214.00

$1,054.00 $1,577.00 $2,026.00 $2,339.00 $2,075.00 $2,284.00 $2,592.00 $2,635.00 $293.00 $487.00 $384.00 $1,896.00 $415.00 $143.00 $189.00 $297.00 $686.00 $130.00 $270.00 $491.00 $155.00 $283.00 $110.00 $202.00 $809.00 $2,448.00 $3,016.00 $1,421.00 $2,591.00 $3,208.00 $806.00 $250.00 $277.00 $46.00 $457.00 $227.00 $75.00 $78.00 $167.00 $484.00 $583.00 $502.00 $625.00 $1,066.00 $1,073.00 $1,324.00 $1,450.00 $411.00 $769.00 $1,285.00


Part B, 252



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 0 0 90 90 90 0 0 0 0 0 0 0 10 10 10 10 90 90 90 90 90 90 90 90 90 10

$1,071.00 $734.00 -------$950.00 -------$685.00 $1,009.00 $879.00 $622.00 $925.00 --------------$653.00 $995.00 $997.00 $769.00 $517.00 $612.00 $693.00 $916.00 $963.00 $70.00 $57.00 $75.00 $124.00 $162.00 ---------------------$96.00 $125.00 $149.00 $141.00 $223.00 $333.00 $89.00 $105.00 $140.00 $159.00 $191.00 $359.00 $319.00 $386.00 $2,036.00 $815.00 $700.00 $486.00 $774.00 $718.00 --------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,372.00 $716.00 $988.00 $1,173.00 $966.00 $976.00 $1,028.00 $1,057.00 $881.00 $1,182.00 $684.00 $1,362.00 $815.00 $1,371.00 $1,600.00 $952.00 $666.00 $763.00 $771.00 $1,072.00 $1,636.00 $195.00 $156.00 $229.00 $168.00 $226.00 $1,312.00 $1,394.00 $1,211.00 $155.00 $218.00 $203.00 $191.00 $396.00 $449.00 $179.00 $144.00 $186.00 $205.00 $207.00 $438.00 $374.00 $499.00 $2,707.00 $1,126.00 $1,225.00 $580.00 $858.00 $812.00 $176.00

$1,443.00 $753.00 $1,039.00 $1,232.00 $1,014.00 $1,026.00 $1,080.00 $1,109.00 $934.00 $1,244.00 $719.00 $1,432.00 $864.00 $1,459.00 $1,717.00 $1,006.00 $700.00 $802.00 $812.00 $1,124.00 $1,716.00 $207.00 $164.00 $241.00 $179.00 $240.00 $1,378.00 $1,465.00 $1,273.00 $164.00 $230.00 $214.00 $202.00 $420.00 $476.00 $190.00 $153.00 $197.00 $217.00 $219.00 $464.00 $395.00 $527.00 $2,898.00 $1,186.00 $1,297.00 $610.00 $902.00 $855.00 $186.00

$1,523.00 $791.00 $1,095.00 $1,298.00 $1,068.00 $1,076.00 $1,135.00 $1,164.00 $988.00 $1,312.00 $756.00 $1,511.00 $921.00 $1,574.00 $1,878.00 $1,066.00 $733.00 $842.00 $854.00 $1,181.00 $1,806.00 $220.00 $174.00 $253.00 $189.00 $253.00 $1,455.00 $1,545.00 $1,340.00 $172.00 $241.00 $224.00 $211.00 $435.00 $493.00 $196.00 $159.00 $206.00 $226.00 $230.00 $487.00 $414.00 $556.00 $3,163.00 $1,255.00 $1,385.00 $639.00 $948.00 $899.00 $194.00

$1,372.00 $716.00 $988.00 $1,173.00 $966.00 $976.00 $1,028.00 $1,057.00 $881.00 $1,182.00 $684.00 $1,362.00 $815.00 $1,371.00 $1,600.00 $952.00 $666.00 $763.00 $771.00 $1,072.00 $1,636.00 $195.00 $156.00 $229.00 $134.00 $182.00 $1,312.00 $1,394.00 $1,211.00 $133.00 $195.00 $160.00 $149.00 $235.00 $271.00 $109.00 $131.00 $166.00 $188.00 $192.00 $396.00 $348.00 $499.00 $2,707.00 $1,126.00 $1,225.00 $580.00 $858.00 $812.00 $161.00

$1,443.00 $753.00 $1,039.00 $1,232.00 $1,014.00 $1,026.00 $1,080.00 $1,109.00 $934.00 $1,244.00 $719.00 $1,432.00 $864.00 $1,459.00 $1,717.00 $1,006.00 $700.00 $802.00 $812.00 $1,124.00 $1,716.00 $207.00 $164.00 $241.00 $141.00 $192.00 $1,378.00 $1,465.00 $1,273.00 $140.00 $205.00 $168.00 $156.00 $247.00 $285.00 $115.00 $139.00 $174.00 $198.00 $203.00 $418.00 $367.00 $527.00 $2,898.00 $1,186.00 $1,297.00 $610.00 $902.00 $855.00 $170.00

$1,523.00 $791.00 $1,095.00 $1,298.00 $1,068.00 $1,076.00 $1,135.00 $1,164.00 $988.00 $1,312.00 $756.00 $1,511.00 $921.00 $1,574.00 $1,878.00 $1,066.00 $733.00 $842.00 $854.00 $1,181.00 $1,806.00 $220.00 $174.00 $253.00 $151.00 $206.00 $1,455.00 $1,545.00 $1,340.00 $148.00 $216.00 $178.00 $165.00 $261.00 $302.00 $121.00 $145.00 $183.00 $207.00 $215.00 $442.00 $386.00 $556.00 $3,163.00 $1,255.00 $1,385.00 $639.00 $948.00 $899.00 $178.00


Part B, 253



90 90 0 0 ZZZ 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90

$279.00 $328.00 $71.00 $74.00 -------$297.00 $1,010.00 $677.00 $1,089.00 $1,110.00 $1,159.00 $1,118.00 $1,562.00 $2,080.00 $2,898.00 $926.00 $1,026.00 $1,120.00 $1,133.00 $1,019.00 $1,121.00 $1,132.00 $1,360.00 $1,089.00 $1,197.00 $1,268.00 $1,318.00 $1,168.00 $71.00 $81.00 $90.00 $24.00 $87.00 $335.00 $408.00 $103.00 $225.00 -------$519.00 $752.00 $663.00 $923.00 ----------------------------$876.00 $1,104.00 -------$1,038.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$455.00 $437.00 $86.00 $155.00 $69.00 $368.00 $1,333.00 $789.00 $1,651.00 $1,470.00 $1,800.00 $1,391.00 $2,012.00 $2,724.00 $4,294.00 $1,184.00 $1,324.00 $1,419.00 $1,514.00 $1,265.00 $1,414.00 $1,504.00 $1,943.00 $1,653.00 $1,782.00 $1,883.00 $1,956.00 $1,751.00 $134.00 $108.00 $121.00 $22.00 $165.00 $390.00 $637.00 $135.00 $1,379.00 $2,579.00 $631.00 $1,181.00 $1,250.00 $1,299.00 $1,027.00 $1,177.00 $1,189.00 $1,301.00 $1,305.00 $1,610.00 $2,809.00 $1,265.00

$482.00 $460.00 $91.00 $164.00 $72.00 $389.00 $1,406.00 $832.00 $1,733.00 $1,555.00 $1,894.00 $1,466.00 $2,142.00 $2,907.00 $4,575.00 $1,245.00 $1,392.00 $1,491.00 $1,592.00 $1,330.00 $1,487.00 $1,579.00 $2,055.00 $1,737.00 $1,871.00 $1,977.00 $2,053.00 $1,840.00 $142.00 $114.00 $128.00 $23.00 $176.00 $409.00 $664.00 $142.00 $1,473.00 $2,756.00 $664.00 $1,247.00 $1,340.00 $1,364.00 $1,079.00 $1,237.00 $1,249.00 $1,371.00 $1,376.00 $1,691.00 $2,999.00 $1,330.00

$508.00 $482.00 $95.00 $171.00 $76.00 $408.00 $1,494.00 $880.00 $1,827.00 $1,659.00 $2,006.00 $1,556.00 $2,316.00 $3,156.00 $4,957.00 $1,312.00 $1,469.00 $1,573.00 $1,681.00 $1,403.00 $1,572.00 $1,664.00 $2,199.00 $1,835.00 $1,973.00 $2,086.00 $2,166.00 $1,943.00 $148.00 $119.00 $133.00 $23.00 $180.00 $430.00 $686.00 $147.00 $1,493.00 $2,793.00 $698.00 $1,327.00 $1,464.00 $1,437.00 $1,137.00 $1,306.00 $1,317.00 $1,453.00 $1,463.00 $1,783.00 $3,259.00 $1,402.00

$455.00 $437.00 $70.00 $126.00 $59.00 $315.00 $1,333.00 $789.00 $1,651.00 $1,470.00 $1,800.00 $1,391.00 $2,012.00 $2,724.00 $4,294.00 $1,184.00 $1,324.00 $1,419.00 $1,514.00 $1,265.00 $1,414.00 $1,504.00 $1,943.00 $1,653.00 $1,782.00 $1,883.00 $1,956.00 $1,751.00 $98.00 $71.00 $84.00 $17.00 $83.00 $390.00 $637.00 $111.00 $313.00 $498.00 $631.00 $1,181.00 $1,250.00 $1,299.00 $1,027.00 $1,177.00 $1,189.00 $1,301.00 $1,305.00 $1,610.00 $2,809.00 $1,265.00

$482.00 $460.00 $74.00 $133.00 $62.00 $332.00 $1,406.00 $832.00 $1,733.00 $1,555.00 $1,894.00 $1,466.00 $2,142.00 $2,907.00 $4,575.00 $1,245.00 $1,392.00 $1,491.00 $1,592.00 $1,330.00 $1,487.00 $1,579.00 $2,055.00 $1,737.00 $1,871.00 $1,977.00 $2,053.00 $1,840.00 $102.00 $74.00 $89.00 $18.00 $88.00 $409.00 $664.00 $117.00 $329.00 $523.00 $664.00 $1,247.00 $1,340.00 $1,364.00 $1,079.00 $1,237.00 $1,249.00 $1,371.00 $1,376.00 $1,691.00 $2,999.00 $1,330.00

$508.00 $482.00 $77.00 $140.00 $65.00 $351.00 $1,494.00 $880.00 $1,827.00 $1,659.00 $2,006.00 $1,556.00 $2,316.00 $3,156.00 $4,957.00 $1,312.00 $1,469.00 $1,573.00 $1,681.00 $1,403.00 $1,572.00 $1,664.00 $2,199.00 $1,835.00 $1,973.00 $2,086.00 $2,166.00 $1,943.00 $108.00 $78.00 $94.00 $19.00 $92.00 $430.00 $686.00 $122.00 $346.00 $554.00 $698.00 $1,327.00 $1,464.00 $1,437.00 $1,137.00 $1,306.00 $1,317.00 $1,453.00 $1,463.00 $1,783.00 $3,259.00 $1,402.00


Part B, 254



90 90 90 0 0 0 0 0 0 0 90 90 90 90 90 YYY YYY 90 90 ZZZ 10 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$853.00 $1,096.00 $1,085.00 $261.00 $340.00 $436.00 $482.00 $677.00 $339.00 $450.00 -----------------------------------BR BR $337.00 $298.00 $47.00 $319.00 $793.00 $804.00 $807.00 $450.00 $463.00 $872.00 $928.00 BR $544.00 $844.00 $508.00 $949.00 $893.00 $769.00 $763.00 $343.00 $509.00 $326.00 $603.00 $469.00 $489.00 $571.00 $820.00 $592.00 $1,368.00 $1,170.00 $1,703.00 $1,876.00 $1,839.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,426.00 $1,636.00 $1,922.00 $437.00 $571.00 $492.00 $554.00 $786.00 $591.00 $2,288.00 $2,560.00 $1,119.00 $1,307.00 $1,472.00 $1,770.00 --------------$519.00 $470.00 $111.00 $347.00 $972.00 $941.00 $1,023.00 $522.00 $521.00 $1,052.00 $1,144.00 -------$1,134.00 $1,071.00 $1,279.00 $1,436.00 $1,341.00 $1,185.00 $1,361.00 $451.00 $576.00 $444.00 $1,102.00 $999.00 $665.00 $1,124.00 $1,082.00 $764.00 $1,732.00 $1,663.00 $2,143.00 $2,425.00 $3,001.00

$1,504.00 $1,721.00 $2,028.00 $463.00 $604.00 $516.00 $581.00 $825.00 $625.00 $2,443.00 $2,733.00 $1,178.00 $1,387.00 $1,552.00 $1,876.00 --------------$546.00 $494.00 $117.00 $365.00 $1,025.00 $993.00 $1,079.00 $550.00 $548.00 $1,104.00 $1,202.00 -------$1,201.00 $1,135.00 $1,352.00 $1,542.00 $1,420.00 $1,251.00 $1,461.00 $475.00 $606.00 $467.00 $1,180.00 $1,051.00 $712.00 $1,205.00 $1,144.00 $812.00 $1,848.00 $1,775.00 $2,286.00 $2,588.00 $3,203.00

$1,597.00 $1,822.00 $2,159.00 $479.00 $628.00 $546.00 $614.00 $873.00 $650.00 $2,477.00 $2,773.00 $1,244.00 $1,488.00 $1,647.00 $2,012.00 --------------$573.00 $518.00 $123.00 $383.00 $1,088.00 $1,057.00 $1,144.00 $578.00 $576.00 $1,164.00 $1,267.00 -------$1,284.00 $1,215.00 $1,440.00 $1,691.00 $1,518.00 $1,330.00 $1,602.00 $496.00 $635.00 $489.00 $1,284.00 $1,109.00 $770.00 $1,316.00 $1,220.00 $869.00 $2,003.00 $1,924.00 $2,480.00 $2,811.00 $3,479.00

$1,426.00 $1,636.00 $1,922.00 $272.00 $384.00 $492.00 $554.00 $786.00 $417.00 $491.00 $619.00 $1,119.00 $1,307.00 $1,472.00 $1,770.00 --------------$519.00 $470.00 $111.00 $347.00 $972.00 $941.00 $1,023.00 $522.00 $521.00 $1,052.00 $1,144.00 -------$1,134.00 $1,071.00 $1,279.00 $1,436.00 $1,341.00 $1,185.00 $1,361.00 $425.00 $576.00 $444.00 $1,102.00 $999.00 $665.00 $1,124.00 $1,082.00 $764.00 $1,732.00 $1,663.00 $2,143.00 $2,425.00 $3,001.00

$1,504.00 $1,721.00 $2,028.00 $286.00 $403.00 $516.00 $581.00 $825.00 $438.00 $515.00 $651.00 $1,178.00 $1,387.00 $1,552.00 $1,876.00 --------------$546.00 $494.00 $117.00 $365.00 $1,025.00 $993.00 $1,079.00 $550.00 $548.00 $1,104.00 $1,202.00 -------$1,201.00 $1,135.00 $1,352.00 $1,542.00 $1,420.00 $1,251.00 $1,461.00 $447.00 $606.00 $467.00 $1,180.00 $1,051.00 $712.00 $1,205.00 $1,144.00 $812.00 $1,848.00 $1,775.00 $2,286.00 $2,588.00 $3,203.00

$1,597.00 $1,822.00 $2,159.00 $302.00 $427.00 $546.00 $614.00 $873.00 $463.00 $544.00 $684.00 $1,244.00 $1,488.00 $1,647.00 $2,012.00 --------------$573.00 $518.00 $123.00 $383.00 $1,088.00 $1,057.00 $1,144.00 $578.00 $576.00 $1,164.00 $1,267.00 -------$1,284.00 $1,215.00 $1,440.00 $1,691.00 $1,518.00 $1,330.00 $1,602.00 $468.00 $635.00 $489.00 $1,284.00 $1,109.00 $770.00 $1,316.00 $1,220.00 $869.00 $2,003.00 $1,924.00 $2,480.00 $2,811.00 $3,479.00


Part B, 255


Surgery CPT Code FUD 2003 MRA 58954 58956 58957 58958 58960 58999 59000 59001 59012 59015 59020 59020-26 59020-TC 59025 59025-26 59025-TC 59030 59050 59051 59100 59120 59121 59130 59135 59136 59140 59150 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618

90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 0

$1,999.00 ---------------------$1,174.00 BR $123.00 $167.00 $267.00 $168.00 $85.00 --------------$54.00 --------------$155.00 $71.00 $47.00 $633.00 $893.00 $768.00 $832.00 $1,083.00 $934.00 $461.00 $543.00 $690.00 $279.00 $79.00 $179.00 $196.00 $316.00 $375.00 $1,816.00 $1,019.00 $1,123.00 $141.00 $134.00 $414.00 $708.00 $140.00 $2,064.00 $1,199.00 $1,324.00 $591.00 $1,805.00 $1,113.00 $1,208.00 $2,035.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$3,263.00 $2,032.00 $2,346.00 $2,574.00 $1,434.00 -------$182.00 $271.00 $306.00 $230.00 $102.00 $55.00 $46.00 $70.00 $45.00 $25.00 $146.00 $77.00 $64.00 $1,170.00 $1,185.00 $1,189.00 $1,391.00 $1,199.00 $1,251.00 $583.00 $1,151.00 $1,117.00 $300.00 $104.00 $283.00 $228.00 $365.00 $395.00 $3,098.00 $1,223.00 $1,559.00 $156.00 $139.00 $667.00 $1,190.00 $270.00 $3,448.00 $1,381.00 $1,896.00 $728.00 $3,270.00 $1,385.00 $1,720.00 $3,497.00

$3,484.00 $2,167.00 $2,506.00 $2,746.00 $1,532.00 -------$195.00 $291.00 $329.00 $247.00 $109.00 $59.00 $50.00 $75.00 $48.00 $27.00 $152.00 $82.00 $68.00 $1,242.00 $1,274.00 $1,280.00 $1,497.00 $1,248.00 $1,330.00 $619.00 $1,239.00 $1,201.00 $323.00 $111.00 $304.00 $246.00 $393.00 $419.00 $3,325.00 $1,312.00 $1,673.00 $167.00 $149.00 $715.00 $1,275.00 $289.00 $3,708.00 $1,484.00 $2,039.00 $782.00 $3,518.00 $1,490.00 $1,851.00 $3,762.00

$3,788.00 $2,346.00 $2,724.00 $2,979.00 $1,662.00 -------$208.00 $322.00 $364.00 $269.00 $116.00 $65.00 $50.00 $80.00 $52.00 $28.00 $158.00 $91.00 $76.00 $1,335.00 $1,401.00 $1,409.00 $1,650.00 $1,292.00 $1,433.00 $659.00 $1,364.00 $1,320.00 $351.00 $119.00 $329.00 $270.00 $434.00 $454.00 $3,631.00 $1,447.00 $1,843.00 $185.00 $166.00 $773.00 $1,376.00 $311.00 $4,066.00 $1,640.00 $2,252.00 $864.00 $3,860.00 $1,653.00 $2,051.00 $4,129.00

$3,263.00 $2,032.00 $2,346.00 $2,574.00 $1,434.00 -------$121.00 $271.00 $306.00 $198.00 $102.00 $55.00 $46.00 $70.00 $45.00 $25.00 $146.00 $77.00 $64.00 $1,170.00 $1,185.00 $1,189.00 $1,391.00 $1,199.00 $1,251.00 $583.00 $1,151.00 $1,117.00 $259.00 $67.00 $223.00 $228.00 $365.00 $395.00 $3,098.00 $1,223.00 $1,559.00 $156.00 $139.00 $534.00 $940.00 $209.00 $3,448.00 $1,381.00 $1,896.00 $728.00 $3,270.00 $1,385.00 $1,720.00 $3,497.00

$3,484.00 $2,167.00 $2,506.00 $2,746.00 $1,532.00 -------$130.00 $291.00 $329.00 $213.00 $109.00 $59.00 $50.00 $75.00 $48.00 $27.00 $152.00 $82.00 $68.00 $1,242.00 $1,274.00 $1,280.00 $1,497.00 $1,248.00 $1,330.00 $619.00 $1,239.00 $1,201.00 $278.00 $72.00 $240.00 $246.00 $393.00 $419.00 $3,325.00 $1,312.00 $1,673.00 $167.00 $149.00 $572.00 $1,007.00 $223.00 $3,708.00 $1,484.00 $2,039.00 $782.00 $3,518.00 $1,490.00 $1,851.00 $3,762.00

$3,788.00 $2,346.00 $2,724.00 $2,979.00 $1,662.00 -------$143.00 $322.00 $364.00 $235.00 $116.00 $65.00 $50.00 $80.00 $52.00 $28.00 $158.00 $91.00 $76.00 $1,335.00 $1,401.00 $1,409.00 $1,650.00 $1,292.00 $1,433.00 $659.00 $1,364.00 $1,320.00 $306.00 $79.00 $264.00 $270.00 $434.00 $454.00 $3,631.00 $1,447.00 $1,843.00 $185.00 $166.00 $630.00 $1,107.00 $246.00 $4,066.00 $1,640.00 $2,252.00 $864.00 $3,860.00 $1,653.00 $2,051.00 $4,129.00


Part B, 256



0 0 90 90 90 90 10 10 90 90 90 90 90 90 0 90 0 YYY YYY 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 90 90 90 90 90 YYY YYY 0

$1,293.00 $1,397.00 $343.00 $389.00 $398.00 $496.00 $331.00 $443.00 $449.00 $464.00 $642.00 $477.00 $577.00 $711.00 $304.00 $348.00 $192.00 BR BR $114.00 $96.00 $744.00 $872.00 $1,170.00 $851.00 $1,107.00 $1,228.00 $1,427.00 $1,911.00 $1,022.00 $1,468.00 $1,210.00 $546.00 $670.00 -------$1,232.00 $1,475.00 $1,631.00 $310.00 $1,405.00 $1,591.00 $1,820.00 $1,272.00 $1,505.00 $1,477.00 $1,624.00 $1,340.00 BR BR $150.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,415.00 $1,950.00 $469.00 $556.00 $562.00 $649.00 $321.00 $568.00 $501.00 $531.00 $724.00 $619.00 $729.00 $747.00 $313.00 $698.00 $200.00 --------------$245.00 $161.00 $971.00 $1,047.00 $1,491.00 $1,044.00 $1,378.00 $1,364.00 $1,962.00 $2,482.00 $1,620.00 $2,034.00 $1,568.00 $646.00 $858.00 $167.00 $1,432.00 $1,914.00 $2,056.00 $365.00 $1,558.00 $1,684.00 $2,039.00 $1,572.00 $1,805.00 $2,091.00 $2,592.00 $1,777.00 --------------$152.00

$1,518.00 $2,099.00 $505.00 $598.00 $604.00 $698.00 $345.00 $611.00 $523.00 $554.00 $756.00 $666.00 $785.00 $778.00 $326.00 $751.00 $215.00 --------------$260.00 $169.00 $1,033.00 $1,116.00 $1,589.00 $1,111.00 $1,469.00 $1,453.00 $2,090.00 $2,638.00 $1,724.00 $2,168.00 $1,669.00 $685.00 $908.00 $177.00 $1,529.00 $2,044.00 $2,190.00 $390.00 $1,669.00 $1,804.00 $2,183.00 $1,673.00 $1,921.00 $2,231.00 $2,767.00 $1,894.00 --------------$164.00

$1,675.00 $2,321.00 $549.00 $646.00 $656.00 $765.00 $376.00 $668.00 $540.00 $572.00 $780.00 $731.00 $863.00 $805.00 $337.00 $817.00 $236.00 --------------$271.00 $175.00 $1,107.00 $1,203.00 $1,715.00 $1,194.00 $1,583.00 $1,570.00 $2,260.00 $2,841.00 $1,858.00 $2,350.00 $1,800.00 $723.00 $959.00 $181.00 $1,657.00 $2,220.00 $2,368.00 $426.00 $1,822.00 $1,975.00 $2,393.00 $1,808.00 $2,078.00 $2,434.00 $3,030.00 $2,057.00 --------------$181.00

$1,415.00 $1,950.00 $439.00 $525.00 $529.00 $649.00 $309.00 $539.00 $501.00 $531.00 $724.00 $619.00 $729.00 $747.00 $313.00 $698.00 $200.00 --------------$221.00 $116.00 $971.00 $1,047.00 $1,491.00 $1,044.00 $1,378.00 $1,364.00 $1,962.00 $2,482.00 $1,620.00 $2,034.00 $1,568.00 $646.00 $858.00 $73.00 $1,432.00 $1,914.00 $2,056.00 $365.00 $1,558.00 $1,684.00 $2,039.00 $1,572.00 $1,805.00 $2,091.00 $2,592.00 $1,777.00 --------------$152.00

$1,518.00 $2,099.00 $472.00 $565.00 $568.00 $698.00 $332.00 $580.00 $523.00 $554.00 $756.00 $666.00 $785.00 $778.00 $326.00 $751.00 $215.00 --------------$235.00 $121.00 $1,033.00 $1,116.00 $1,589.00 $1,111.00 $1,469.00 $1,453.00 $2,090.00 $2,638.00 $1,724.00 $2,168.00 $1,669.00 $685.00 $908.00 $77.00 $1,529.00 $2,044.00 $2,190.00 $390.00 $1,669.00 $1,804.00 $2,183.00 $1,673.00 $1,921.00 $2,231.00 $2,767.00 $1,894.00 --------------$164.00

$1,675.00 $2,321.00 $516.00 $613.00 $619.00 $765.00 $363.00 $637.00 $540.00 $572.00 $780.00 $731.00 $863.00 $805.00 $337.00 $817.00 $236.00 --------------$246.00 $126.00 $1,107.00 $1,203.00 $1,715.00 $1,194.00 $1,583.00 $1,570.00 $2,260.00 $2,841.00 $1,858.00 $2,350.00 $1,800.00 $723.00 $959.00 $81.00 $1,657.00 $2,220.00 $2,368.00 $426.00 $1,822.00 $1,975.00 $2,393.00 $1,808.00 $2,078.00 $2,434.00 $3,030.00 $2,057.00 --------------$181.00


Part B, 257



0 0 0 0 90 0 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90

$138.00 $106.00 $143.00 $67.00 $503.00 $863.00 $959.00 $733.00 $1,389.00 $1,503.00 $795.00 $1,393.00 $1,473.00 $527.00 $637.00 $888.00 $1,042.00 $2,005.00 $2,419.00 $2,187.00 $2,207.00 $2,200.00 $2,393.00 $88.00 $2,118.00 $2,310.00 $1,779.00 $1,842.00 $1,706.00 $2,307.00 $2,231.00 $1,584.00 $2,673.00 $2,259.00 $2,173.00 $2,433.00 $2,426.00 $1,922.00 $1,637.00 $1,353.00 $2,506.00 $2,981.00 $2,262.00 $2,253.00 $74.00 $3,163.00 $3,450.00 $4,349.00 $3,667.00 $2,415.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$151.00 $125.00 $178.00 $85.00 $691.00 $494.00 $1,385.00 $1,141.00 $1,946.00 $2,064.00 $1,538.00 $1,951.00 $1,921.00 $580.00 $768.00 $1,225.00 $1,201.00 $2,540.00 $3,101.00 $3,222.00 $3,067.00 $2,813.00 $3,200.00 $138.00 $2,941.00 $3,246.00 $3,683.00 $3,738.00 $2,351.00 $2,567.00 $2,662.00 $2,191.00 $3,396.00 $3,147.00 $2,979.00 $3,104.00 $3,279.00 $2,375.00 $2,005.00 $1,744.00 $3,372.00 $3,945.00 $2,932.00 $2,861.00 $138.00 $4,263.00 $4,536.00 $5,817.00 $4,885.00 $3,355.00

$160.00 $131.00 $189.00 $90.00 $754.00 $542.00 $1,514.00 $1,249.00 $2,130.00 $2,260.00 $1,687.00 $2,135.00 $2,105.00 $637.00 $839.00 $1,325.00 $1,269.00 $2,782.00 $3,400.00 $3,532.00 $3,360.00 $3,080.00 $3,508.00 $152.00 $3,222.00 $3,554.00 $4,038.00 $4,104.00 $2,473.00 $2,682.00 $2,793.00 $2,392.00 $3,721.00 $3,449.00 $3,267.00 $3,401.00 $3,600.00 $2,504.00 $2,174.00 $1,889.00 $3,694.00 $4,322.00 $3,210.00 $3,132.00 $152.00 $4,671.00 $4,967.00 $6,355.00 $5,354.00 $3,675.00

$170.00 $137.00 $203.00 $97.00 $838.00 $620.00 $1,694.00 $1,403.00 $2,402.00 $2,554.00 $1,907.00 $2,403.00 $2,381.00 $730.00 $934.00 $1,461.00 $1,346.00 $3,146.00 $3,854.00 $4,007.00 $3,802.00 $3,481.00 $3,975.00 $174.00 $3,648.00 $4,023.00 $4,581.00 $4,672.00 $2,585.00 $2,766.00 $2,909.00 $2,689.00 $4,215.00 $3,909.00 $3,708.00 $3,854.00 $4,092.00 $2,655.00 $2,413.00 $2,088.00 $4,178.00 $4,902.00 $3,630.00 $3,540.00 $174.00 $5,294.00 $5,632.00 $7,179.00 $6,081.00 $4,165.00

$151.00 $125.00 $178.00 $85.00 $691.00 $494.00 $1,385.00 $1,141.00 $1,946.00 $2,064.00 $1,538.00 $1,951.00 $1,921.00 $580.00 $768.00 $1,225.00 $1,201.00 $2,540.00 $3,101.00 $3,222.00 $3,067.00 $2,813.00 $3,200.00 $138.00 $2,941.00 $3,246.00 $3,683.00 $3,738.00 $2,351.00 $2,567.00 $2,662.00 $2,191.00 $3,396.00 $3,147.00 $2,979.00 $3,104.00 $3,279.00 $2,375.00 $2,005.00 $1,744.00 $3,372.00 $3,945.00 $2,932.00 $2,861.00 $138.00 $4,263.00 $4,536.00 $5,817.00 $4,885.00 $3,355.00

$160.00 $131.00 $189.00 $90.00 $754.00 $542.00 $1,514.00 $1,249.00 $2,130.00 $2,260.00 $1,687.00 $2,135.00 $2,105.00 $637.00 $839.00 $1,325.00 $1,269.00 $2,782.00 $3,400.00 $3,532.00 $3,360.00 $3,080.00 $3,508.00 $152.00 $3,222.00 $3,554.00 $4,038.00 $4,104.00 $2,473.00 $2,682.00 $2,793.00 $2,392.00 $3,721.00 $3,449.00 $3,267.00 $3,401.00 $3,600.00 $2,504.00 $2,174.00 $1,889.00 $3,694.00 $4,322.00 $3,210.00 $3,132.00 $152.00 $4,671.00 $4,967.00 $6,355.00 $5,354.00 $3,675.00

$170.00 $137.00 $203.00 $97.00 $838.00 $620.00 $1,694.00 $1,403.00 $2,402.00 $2,554.00 $1,907.00 $2,403.00 $2,381.00 $730.00 $934.00 $1,461.00 $1,346.00 $3,146.00 $3,854.00 $4,007.00 $3,802.00 $3,481.00 $3,975.00 $174.00 $3,648.00 $4,023.00 $4,581.00 $4,672.00 $2,585.00 $2,766.00 $2,909.00 $2,689.00 $4,215.00 $3,909.00 $3,708.00 $3,854.00 $4,092.00 $2,655.00 $2,413.00 $2,088.00 $4,178.00 $4,902.00 $3,630.00 $3,540.00 $174.00 $5,294.00 $5,632.00 $7,179.00 $6,081.00 $4,165.00


Part B, 258



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

$2,484.00 $3,918.00 $3,611.00 $1,344.00 $1,712.00 $1,535.00 $958.00 $2,862.00 -------$2,466.00 $2,660.00 -------$2,363.00 $2,307.00 $2,271.00 $3,474.00 $2,695.00 $1,964.00 $1,141.00 $1,463.00 $1,760.00 $1,807.00 $2,085.00 $2,700.00 $2,175.00 $2,597.00 --------------$1,975.00 $2,140.00 $2,992.00 $3,772.00 $2,383.00 $2,674.00 $2,557.00 $2,972.00 $2,830.00 $3,142.00 $2,097.00 $3,299.00 $3,491.00 $3,245.00 $2,350.00 $2,827.00 $3,046.00 $2,693.00 $2,039.00 $2,279.00 $2,299.00 $3,178.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$3,205.00 $5,709.00 $4,811.00 $1,872.00 $2,348.00 $2,498.00 $1,526.00 $4,027.00 $3,819.00 $4,163.00 $3,632.00 $3,402.00 $3,349.00 $3,251.00 $2,964.00 $4,970.00 $3,599.00 $2,407.00 $1,414.00 $1,705.00 $2,397.00 $2,449.00 $2,919.00 $3,150.00 $2,942.00 $3,527.00 $3,481.00 $3,995.00 $2,884.00 $3,077.00 $3,180.00 $5,382.00 $3,727.00 $3,893.00 $4,372.00 $4,424.00 $4,363.00 $4,961.00 $3,644.00 $4,517.00 $4,631.00 $4,855.00 $3,521.00 $3,577.00 $4,306.00 $4,344.00 $3,173.00 $3,682.00 $3,200.00 $4,553.00

$3,514.00 $6,271.00 $5,285.00 $2,050.00 $2,573.00 $2,729.00 $1,670.00 $4,423.00 $4,187.00 $4,571.00 $3,977.00 $3,735.00 $3,676.00 $3,541.00 $3,254.00 $5,458.00 $3,951.00 $2,619.00 $1,495.00 $1,798.00 $2,593.00 $2,666.00 $3,204.00 $3,367.00 $3,214.00 $3,828.00 $3,817.00 $4,386.00 $3,161.00 $3,375.00 $3,371.00 $5,745.00 $4,002.00 $4,125.00 $4,757.00 $4,835.00 $4,768.00 $5,438.00 $3,980.00 $4,816.00 $4,961.00 $5,301.00 $3,779.00 $3,779.00 $4,689.00 $4,755.00 $3,400.00 $4,018.00 $3,398.00 $4,959.00

$3,986.00 $7,152.00 $6,026.00 $2,312.00 $2,913.00 $3,070.00 $1,877.00 $5,037.00 $4,758.00 $5,209.00 $4,505.00 $4,247.00 $4,180.00 $3,972.00 $3,699.00 $6,213.00 $4,496.00 $2,934.00 $1,584.00 $1,908.00 $2,875.00 $2,984.00 $3,635.00 $3,654.00 $3,628.00 $4,267.00 $4,331.00 $4,989.00 $3,581.00 $3,828.00 $3,612.00 $6,191.00 $4,335.00 $4,361.00 $5,258.00 $5,425.00 $5,345.00 $6,132.00 $4,419.00 $5,181.00 $5,385.00 $5,942.00 $4,101.00 $4,000.00 $5,249.00 $5,339.00 $3,670.00 $4,486.00 $3,617.00 $5,542.00

$3,205.00 $5,709.00 $4,811.00 $1,872.00 $2,348.00 $2,498.00 $1,526.00 $4,027.00 $3,819.00 $4,163.00 $3,632.00 $3,402.00 $3,349.00 $3,251.00 $2,964.00 $4,970.00 $3,599.00 $2,407.00 $1,414.00 $1,705.00 $2,397.00 $2,449.00 $2,919.00 $3,150.00 $2,942.00 $3,527.00 $3,481.00 $3,995.00 $2,884.00 $3,077.00 $3,180.00 $5,382.00 $3,727.00 $3,893.00 $4,372.00 $4,424.00 $4,363.00 $4,961.00 $3,644.00 $4,517.00 $4,631.00 $4,855.00 $3,521.00 $3,577.00 $4,306.00 $4,344.00 $3,173.00 $3,682.00 $3,200.00 $4,553.00

$3,514.00 $6,271.00 $5,285.00 $2,050.00 $2,573.00 $2,729.00 $1,670.00 $4,423.00 $4,187.00 $4,571.00 $3,977.00 $3,735.00 $3,676.00 $3,541.00 $3,254.00 $5,458.00 $3,951.00 $2,619.00 $1,495.00 $1,798.00 $2,593.00 $2,666.00 $3,204.00 $3,367.00 $3,214.00 $3,828.00 $3,817.00 $4,386.00 $3,161.00 $3,375.00 $3,371.00 $5,745.00 $4,002.00 $4,125.00 $4,757.00 $4,835.00 $4,768.00 $5,438.00 $3,980.00 $4,816.00 $4,961.00 $5,301.00 $3,779.00 $3,779.00 $4,689.00 $4,755.00 $3,400.00 $4,018.00 $3,398.00 $4,959.00

$3,986.00 $7,152.00 $6,026.00 $2,312.00 $2,913.00 $3,070.00 $1,877.00 $5,037.00 $4,758.00 $5,209.00 $4,505.00 $4,247.00 $4,180.00 $3,972.00 $3,699.00 $6,213.00 $4,496.00 $2,934.00 $1,584.00 $1,908.00 $2,875.00 $2,984.00 $3,635.00 $3,654.00 $3,628.00 $4,267.00 $4,331.00 $4,989.00 $3,581.00 $3,828.00 $3,612.00 $6,191.00 $4,335.00 $4,361.00 $5,258.00 $5,425.00 $5,345.00 $6,132.00 $4,419.00 $5,181.00 $5,385.00 $5,942.00 $4,101.00 $4,000.00 $5,249.00 $5,339.00 $3,670.00 $4,486.00 $3,617.00 $5,542.00


Part B, 259



90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 ZZZ 90

$2,961.00 $3,458.00 $2,354.00 $584.00 $2,219.00 $3,375.00 $2,576.00 $3,535.00 $1,389.00 $1,682.00 $540.00 $1,073.00 $877.00 --------------------------------------------------------$2,758.00 $4,798.00 $3,341.00 $5,012.00 $2,556.00 $4,007.00 $3,231.00 $3,103.00 $4,037.00 $4,019.00 $1,444.00 $3,043.00 $2,546.00 $2,129.00 $3,150.00 $1,558.00 $1,664.00 $1,521.00 $1,628.00 $1,670.00 $1,867.00 ---------------------$952.00 $1,205.00 ----------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$4,089.00 $4,988.00 $2,296.00 $574.00 $2,158.00 $4,934.00 $3,347.00 $5,088.00 $1,978.00 $2,181.00 $861.00 $1,733.00 $1,281.00 $2,010.00 $2,151.00 $956.00 $335.00 $671.00 $1,171.00 $777.00 $330.00 $3,465.00 $6,469.00 $4,442.00 $6,981.00 $3,351.00 $5,665.00 $6,573.00 $7,220.00 $5,276.00 $6,245.00 $2,108.00 $3,960.00 $3,123.00 $3,357.00 $4,019.00 $1,970.00 $2,437.00 $2,176.00 $2,133.00 $2,458.00 $2,510.00 $369.00 $261.00 $361.00 $1,355.00 $1,640.00 $1,567.00 $347.00 $2,143.00

$4,405.00 $5,451.00 $2,417.00 $604.00 $2,272.00 $5,380.00 $3,544.00 $5,540.00 $2,150.00 $2,353.00 $926.00 $1,864.00 $1,352.00 $2,163.00 $2,306.00 $1,006.00 $353.00 $706.00 $1,248.00 $825.00 $350.00 $3,794.00 $7,092.00 $4,878.00 $7,660.00 $3,670.00 $6,211.00 $7,211.00 $7,928.00 $5,783.00 $6,853.00 $2,312.00 $4,324.00 $3,296.00 $3,686.00 $4,403.00 $2,162.00 $2,672.00 $2,386.00 $2,339.00 $2,698.00 $2,753.00 $404.00 $276.00 $394.00 $1,484.00 $1,789.00 $1,717.00 $382.00 $2,348.00

$4,836.00 $6,133.00 $2,576.00 $644.00 $2,421.00 $6,024.00 $3,762.00 $6,189.00 $2,398.00 $2,592.00 $1,024.00 $2,066.00 $1,451.00 $2,388.00 $2,531.00 $1,072.00 $376.00 $753.00 $1,367.00 $896.00 $381.00 $4,295.00 $8,073.00 $5,556.00 $8,727.00 $4,154.00 $7,062.00 $8,210.00 $9,047.00 $6,568.00 $7,805.00 $2,619.00 $4,874.00 $3,506.00 $4,196.00 $4,994.00 $2,449.00 $3,027.00 $2,704.00 $2,644.00 $3,063.00 $3,125.00 $462.00 $295.00 $446.00 $1,672.00 $2,007.00 $1,940.00 $438.00 $2,661.00

$4,089.00 $4,988.00 $2,296.00 $574.00 $2,158.00 $4,934.00 $3,347.00 $5,088.00 $1,978.00 $2,181.00 $861.00 $1,733.00 $1,281.00 $2,010.00 $2,151.00 $956.00 $335.00 $671.00 $1,171.00 $777.00 $330.00 $3,465.00 $6,469.00 $4,442.00 $6,981.00 $3,351.00 $5,665.00 $6,573.00 $7,220.00 $5,276.00 $6,245.00 $2,108.00 $3,960.00 $3,123.00 $3,357.00 $4,019.00 $1,970.00 $2,437.00 $2,176.00 $2,133.00 $2,458.00 $2,510.00 $369.00 $261.00 $361.00 $1,355.00 $1,640.00 $1,567.00 $347.00 $2,143.00

$4,405.00 $5,451.00 $2,417.00 $604.00 $2,272.00 $5,380.00 $3,544.00 $5,540.00 $2,150.00 $2,353.00 $926.00 $1,864.00 $1,352.00 $2,163.00 $2,306.00 $1,006.00 $353.00 $706.00 $1,248.00 $825.00 $350.00 $3,794.00 $7,092.00 $4,878.00 $7,660.00 $3,670.00 $6,211.00 $7,211.00 $7,928.00 $5,783.00 $6,853.00 $2,312.00 $4,324.00 $3,296.00 $3,686.00 $4,403.00 $2,162.00 $2,672.00 $2,386.00 $2,339.00 $2,698.00 $2,753.00 $404.00 $276.00 $394.00 $1,484.00 $1,789.00 $1,717.00 $382.00 $2,348.00

$4,836.00 $6,133.00 $2,576.00 $644.00 $2,421.00 $6,024.00 $3,762.00 $6,189.00 $2,398.00 $2,592.00 $1,024.00 $2,066.00 $1,451.00 $2,388.00 $2,531.00 $1,072.00 $376.00 $753.00 $1,367.00 $896.00 $381.00 $4,295.00 $8,073.00 $5,556.00 $8,727.00 $4,154.00 $7,062.00 $8,210.00 $9,047.00 $6,568.00 $7,805.00 $2,619.00 $4,874.00 $3,506.00 $4,196.00 $4,994.00 $2,449.00 $3,027.00 $2,704.00 $2,644.00 $3,063.00 $3,125.00 $462.00 $295.00 $446.00 $1,672.00 $2,007.00 $1,940.00 $438.00 $2,661.00


Part B, 260


Surgery CPT Code FUD 2003 MRA 61799 61800 61850 61860 61863 61864 61867 61868 61870 61880 61885 61886 61888 62000 62005 62010 62100 62115 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62148 62160 62161 62162 62163 62164 62165 62180 62190 62192 62194 62200 62201 62220 62223 62225 62230 62252 62252-26 62252-TC 62256 62258

ZZZ ZZZ 90 90 90 ZZZ 90 ZZZ 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 0 0 90 90

--------------$1,090.00 $1,197.00 ----------------------------$616.00 $559.00 $262.00 $678.00 $331.00 $848.00 $1,282.00 $1,754.00 $1,962.00 $1,686.00 $2,211.00 $1,898.00 $1,822.00 $1,221.00 $1,955.00 $1,011.00 $1,096.00 $1,566.00 $1,327.00 $1,566.00 $120.00 $172.00 $1,229.00 $1,578.00 $999.00 $1,706.00 $1,336.00 $1,695.00 $1,034.00 $1,146.00 $239.00 $1,625.00 $1,200.00 $1,215.00 $1,199.00 $488.00 $935.00 $85.00 --------------$616.00 $1,308.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$478.00 $240.00 $1,519.00 $2,435.00 $2,316.00 $447.00 $3,531.00 $784.00 $1,749.00 $868.00 $777.00 $1,279.00 $606.00 $1,593.00 $1,910.00 $2,360.00 $2,445.00 $1,922.00 $2,401.00 $2,442.00 $2,389.00 $1,577.00 $1,739.00 $1,355.00 $1,592.00 $2,170.00 $1,915.00 $2,168.00 $200.00 $299.00 $2,348.00 $2,924.00 $1,679.00 $3,210.00 $2,349.00 $2,466.00 $1,346.00 $1,496.00 $703.00 $2,129.00 $1,858.00 $1,580.00 $1,602.00 $797.00 $1,291.00 $126.00 $72.00 $53.00 $910.00 $1,729.00

$526.00 $264.00 $1,665.00 $2,673.00 $2,538.00 $492.00 $3,870.00 $861.00 $1,901.00 $948.00 $846.00 $1,396.00 $662.00 $1,747.00 $2,087.00 $2,586.00 $2,663.00 $2,026.00 $2,532.00 $2,587.00 $2,568.00 $1,718.00 $1,895.00 $1,480.00 $1,741.00 $2,373.00 $2,098.00 $2,359.00 $220.00 $329.00 $2,573.00 $3,208.00 $1,809.00 $3,517.00 $2,545.00 $2,702.00 $1,467.00 $1,636.00 $767.00 $2,334.00 $2,036.00 $1,728.00 $1,750.00 $871.00 $1,411.00 $136.00 $79.00 $57.00 $995.00 $1,891.00

$602.00 $300.00 $1,882.00 $3,035.00 $2,867.00 $563.00 $4,390.00 $985.00 $2,117.00 $1,057.00 $936.00 $1,551.00 $743.00 $1,974.00 $2,350.00 $2,924.00 $2,986.00 $2,150.00 $2,685.00 $2,735.00 $2,798.00 $1,922.00 $2,122.00 $1,659.00 $1,959.00 $2,674.00 $2,369.00 $2,640.00 $253.00 $378.00 $2,911.00 $3,639.00 $1,984.00 $3,979.00 $2,825.00 $3,057.00 $1,639.00 $1,839.00 $854.00 $2,644.00 $2,296.00 $1,944.00 $1,960.00 $970.00 $1,586.00 $148.00 $90.00 $58.00 $1,111.00 $2,128.00

$478.00 $240.00 $1,519.00 $2,435.00 $2,316.00 $447.00 $3,531.00 $784.00 $1,749.00 $868.00 $777.00 $1,279.00 $606.00 $1,593.00 $1,910.00 $2,360.00 $2,445.00 $1,922.00 $2,401.00 $2,442.00 $2,389.00 $1,577.00 $1,739.00 $1,355.00 $1,592.00 $2,170.00 $1,915.00 $2,168.00 $200.00 $299.00 $2,348.00 $2,924.00 $1,679.00 $3,210.00 $2,349.00 $2,466.00 $1,346.00 $1,496.00 $703.00 $2,129.00 $1,858.00 $1,580.00 $1,602.00 $797.00 $1,291.00 $126.00 $72.00 $53.00 $910.00 $1,729.00

$526.00 $264.00 $1,665.00 $2,673.00 $2,538.00 $492.00 $3,870.00 $861.00 $1,901.00 $948.00 $846.00 $1,396.00 $662.00 $1,747.00 $2,087.00 $2,586.00 $2,663.00 $2,026.00 $2,532.00 $2,587.00 $2,568.00 $1,718.00 $1,895.00 $1,480.00 $1,741.00 $2,373.00 $2,098.00 $2,359.00 $220.00 $329.00 $2,573.00 $3,208.00 $1,809.00 $3,517.00 $2,545.00 $2,702.00 $1,467.00 $1,636.00 $767.00 $2,334.00 $2,036.00 $1,728.00 $1,750.00 $871.00 $1,411.00 $136.00 $79.00 $57.00 $995.00 $1,891.00

$602.00 $300.00 $1,882.00 $3,035.00 $2,867.00 $563.00 $4,390.00 $985.00 $2,117.00 $1,057.00 $936.00 $1,551.00 $743.00 $1,974.00 $2,350.00 $2,924.00 $2,986.00 $2,150.00 $2,685.00 $2,735.00 $2,798.00 $1,922.00 $2,122.00 $1,659.00 $1,959.00 $2,674.00 $2,369.00 $2,640.00 $253.00 $378.00 $2,911.00 $3,639.00 $1,984.00 $3,979.00 $2,825.00 $3,057.00 $1,639.00 $1,839.00 $854.00 $2,644.00 $2,296.00 $1,944.00 $1,960.00 $970.00 $1,586.00 $148.00 $90.00 $58.00 $1,111.00 $2,128.00


Part B, 261



10 10 0 0 0 0 0 0 10 10 10 0 90 0 0 90 90 0 0 0 0 0 0 0 0 10 90 10 10 10 10 10 0 0 0 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 ZZZ

$426.00 $593.00 -------$285.00 $271.00 $109.00 $137.00 $130.00 $199.00 $186.00 $211.00 $196.00 $784.00 $235.00 $232.00 $1,064.00 $821.00 ----------------------------$200.00 $201.00 $208.00 $203.00 $488.00 $782.00 $402.00 $195.00 $390.00 $517.00 $418.00 BR BR --------------$1,882.00 $1,591.00 $1,390.00 $1,151.00 $1,568.00 $1,862.00 $1,788.00 $1,489.00 $1,395.00 $1,145.00 $280.00 $1,764.00 $1,620.00 BR

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$913.00 $596.00 $353.00 $378.00 $397.00 $225.00 $285.00 $246.00 $431.00 $342.00 $412.00 $256.00 $824.00 $470.00 $465.00 $839.00 $1,134.00 $339.00 $352.00 $336.00 $366.00 $336.00 $310.00 $323.00 $237.00 $592.00 $1,305.00 $396.00 $461.00 $532.00 $573.00 $439.00 $59.00 $81.00 $168.00 $177.00 $1,898.00 $1,883.00 $1,792.00 $1,641.00 $1,804.00 $2,271.00 $2,314.00 $1,908.00 $1,754.00 $1,456.00 $293.00 $2,107.00 $1,949.00 --------

$967.00 $629.00 $372.00 $395.00 $416.00 $239.00 $306.00 $259.00 $458.00 $363.00 $438.00 $272.00 $866.00 $497.00 $492.00 $877.00 $1,185.00 $359.00 $373.00 $355.00 $387.00 $356.00 $329.00 $341.00 $250.00 $630.00 $1,413.00 $423.00 $493.00 $569.00 $613.00 $471.00 $62.00 $85.00 $178.00 $188.00 $2,069.00 $2,048.00 $1,948.00 $1,768.00 $1,957.00 $2,478.00 $2,517.00 $2,078.00 $1,902.00 $1,576.00 $317.00 $2,283.00 $2,105.00 --------

$985.00 $645.00 $383.00 $413.00 $439.00 $247.00 $318.00 $267.00 $472.00 $377.00 $450.00 $278.00 $906.00 $510.00 $502.00 $907.00 $1,225.00 $368.00 $382.00 $364.00 $396.00 $363.00 $335.00 $348.00 $257.00 $675.00 $1,554.00 $453.00 $531.00 $614.00 $662.00 $507.00 $64.00 $88.00 $182.00 $192.00 $2,319.00 $2,287.00 $2,167.00 $1,938.00 $2,173.00 $2,780.00 $2,810.00 $2,321.00 $2,107.00 $1,736.00 $354.00 $2,532.00 $2,317.00 --------

$488.00 $347.00 $233.00 $378.00 $397.00 $114.00 $124.00 $166.00 $235.00 $229.00 $211.00 $125.00 $824.00 $251.00 $248.00 $839.00 $1,134.00 $179.00 $182.00 $176.00 $184.00 $157.00 $130.00 $145.00 $139.00 $592.00 $1,305.00 $396.00 $461.00 $532.00 $573.00 $439.00 $37.00 $52.00 $52.00 $68.00 $1,898.00 $1,883.00 $1,792.00 $1,641.00 $1,804.00 $2,271.00 $2,314.00 $1,908.00 $1,754.00 $1,456.00 $293.00 $2,107.00 $1,949.00 --------

$511.00 $362.00 $243.00 $395.00 $416.00 $121.00 $133.00 $173.00 $247.00 $242.00 $223.00 $131.00 $866.00 $263.00 $259.00 $877.00 $1,185.00 $187.00 $190.00 $184.00 $192.00 $164.00 $136.00 $150.00 $145.00 $630.00 $1,413.00 $423.00 $493.00 $569.00 $613.00 $471.00 $39.00 $54.00 $55.00 $71.00 $2,069.00 $2,048.00 $1,948.00 $1,768.00 $1,957.00 $2,478.00 $2,517.00 $2,078.00 $1,902.00 $1,576.00 $317.00 $2,283.00 $2,105.00 --------

$527.00 $377.00 $253.00 $413.00 $439.00 $128.00 $145.00 $180.00 $261.00 $255.00 $234.00 $138.00 $906.00 $274.00 $269.00 $907.00 $1,225.00 $195.00 $198.00 $192.00 $200.00 $171.00 $141.00 $156.00 $152.00 $675.00 $1,554.00 $453.00 $531.00 $614.00 $662.00 $507.00 $41.00 $57.00 $57.00 $75.00 $2,319.00 $2,287.00 $2,167.00 $1,938.00 $2,173.00 $2,780.00 $2,810.00 $2,321.00 $2,107.00 $1,736.00 $354.00 $2,532.00 $2,317.00 --------


Part B, 262



ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

BR $1,647.00 $2,117.00 $1,907.00 $367.00 --------------$2,029.00 $1,960.00 $421.00 $2,200.00 $263.00 $1,720.00 $383.00 $1,828.00 $261.00 $2,203.00 $391.00 $2,416.00 $282.00 $2,930.00 $381.00 $2,490.00 $249.00 ---------------------$1,788.00 $1,672.00 $1,851.00 $1,486.00 $1,711.00 $1,347.00 $1,610.00 $1,444.00 $1,593.00 $1,603.00 $1,810.00 $1,725.00 $1,956.00 $2,258.00 $1,569.00 $3,182.00 $3,207.00 $3,319.00 $1,940.00 $2,053.00 $1,651.00 $1,469.00 $2,197.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

-------$1,961.00 $1,844.00 $1,662.00 $324.00 $2,251.00 $2,587.00 $2,491.00 $2,245.00 $490.00 $2,693.00 $326.00 $2,054.00 $379.00 $2,265.00 $293.00 $2,667.00 $409.00 $2,898.00 $291.00 $3,647.00 $396.00 $2,927.00 $267.00 $3,528.00 $3,436.00 $449.00 $2,473.00 $2,124.00 $2,645.00 $2,305.00 $2,101.00 $1,700.00 $1,882.00 $2,074.00 $2,478.00 $2,389.00 $2,078.00 $2,660.00 $2,448.00 $2,570.00 $2,358.00 $4,311.00 $4,723.00 $4,717.00 $2,562.00 $2,634.00 $2,083.00 $2,204.00 $3,226.00

-------$2,134.00 $1,999.00 $1,800.00 $351.00 $2,435.00 $2,799.00 $2,715.00 $2,431.00 $531.00 $2,925.00 $359.00 $2,228.00 $412.00 $2,446.00 $315.00 $2,890.00 $443.00 $3,136.00 $315.00 $3,943.00 $428.00 $3,140.00 $286.00 $3,836.00 $3,716.00 $486.00 $2,713.00 $2,317.00 $2,898.00 $2,528.00 $2,262.00 $1,832.00 $2,020.00 $2,262.00 $2,718.00 $2,622.00 $2,190.00 $2,919.00 $2,580.00 $2,708.00 $2,580.00 $4,687.00 $5,183.00 $5,175.00 $2,798.00 $2,875.00 $2,264.00 $2,412.00 $3,539.00

-------$2,381.00 $2,211.00 $1,987.00 $393.00 $2,691.00 $3,099.00 $3,046.00 $2,696.00 $594.00 $3,262.00 $412.00 $2,472.00 $462.00 $2,702.00 $347.00 $3,210.00 $497.00 $3,481.00 $352.00 $4,371.00 $476.00 $3,430.00 $313.00 $4,285.00 $4,112.00 $543.00 $3,075.00 $2,599.00 $3,279.00 $2,863.00 $2,494.00 $2,007.00 $2,201.00 $2,535.00 $3,079.00 $2,974.00 $2,327.00 $3,311.00 $2,741.00 $2,877.00 $2,910.00 $5,257.00 $5,899.00 $5,888.00 $3,148.00 $3,232.00 $2,524.00 $2,719.00 $4,019.00

-------$1,961.00 $1,844.00 $1,662.00 $324.00 $2,251.00 $2,587.00 $2,491.00 $2,245.00 $490.00 $2,693.00 $326.00 $2,054.00 $379.00 $2,265.00 $293.00 $2,667.00 $409.00 $2,898.00 $291.00 $3,647.00 $396.00 $2,927.00 $267.00 $3,528.00 $3,436.00 $449.00 $2,473.00 $2,124.00 $2,645.00 $2,305.00 $2,101.00 $1,700.00 $1,882.00 $2,074.00 $2,478.00 $2,389.00 $2,078.00 $2,660.00 $2,448.00 $2,570.00 $2,358.00 $4,311.00 $4,723.00 $4,717.00 $2,562.00 $2,634.00 $2,083.00 $2,204.00 $3,226.00

-------$2,134.00 $1,999.00 $1,800.00 $351.00 $2,435.00 $2,799.00 $2,715.00 $2,431.00 $531.00 $2,925.00 $359.00 $2,228.00 $412.00 $2,446.00 $315.00 $2,890.00 $443.00 $3,136.00 $315.00 $3,943.00 $428.00 $3,140.00 $286.00 $3,836.00 $3,716.00 $486.00 $2,713.00 $2,317.00 $2,898.00 $2,528.00 $2,262.00 $1,832.00 $2,020.00 $2,262.00 $2,718.00 $2,622.00 $2,190.00 $2,919.00 $2,580.00 $2,708.00 $2,580.00 $4,687.00 $5,183.00 $5,175.00 $2,798.00 $2,875.00 $2,264.00 $2,412.00 $3,539.00

-------$2,381.00 $2,211.00 $1,987.00 $393.00 $2,691.00 $3,099.00 $3,046.00 $2,696.00 $594.00 $3,262.00 $412.00 $2,472.00 $462.00 $2,702.00 $347.00 $3,210.00 $497.00 $3,481.00 $352.00 $4,371.00 $476.00 $3,430.00 $313.00 $4,285.00 $4,112.00 $543.00 $3,075.00 $2,599.00 $3,279.00 $2,863.00 $2,494.00 $2,007.00 $2,201.00 $2,535.00 $3,079.00 $2,974.00 $2,327.00 $3,311.00 $2,741.00 $2,877.00 $2,910.00 $5,257.00 $5,899.00 $5,888.00 $3,148.00 $3,232.00 $2,524.00 $2,719.00 $4,019.00


Part B, 263



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 0 90 90 ZZZ 10 90 10 90 10 90 10 10 90 90 90 90 90 90 90 90 90 90 90 0

$2,401.00 $2,206.00 $2,012.00 $2,166.00 $2,135.00 $1,905.00 $1,877.00 $2,529.00 $2,496.00 $2,305.00 $2,041.00 $2,934.00 $3,003.00 $3,012.00 $3,073.00 -------$2,006.00 $2,209.00 $2,290.00 $2,357.00 $2,513.00 $2,574.00 $2,596.00 $2,522.00 $425.00 $797.00 $476.00 $1,348.00 --------------$819.00 $1,064.00 ----------------------------$615.00 $707.00 $1,340.00 $1,512.00 $1,708.00 $1,873.00 $1,041.00 $1,310.00 $1,165.00 $1,062.00 $741.00 $738.00 $529.00 $78.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$3,187.00 $2,894.00 $2,881.00 $2,762.00 $2,739.00 $2,361.00 $2,466.00 $3,260.00 $3,217.00 $3,024.00 $2,912.00 $4,068.00 $4,000.00 $4,286.00 $4,261.00 $523.00 $2,813.00 $3,417.00 $3,360.00 $3,582.00 $3,604.00 $3,733.00 $3,490.00 $3,517.00 $502.00 $1,317.00 $623.00 $1,435.00 $1,726.00 $399.00 $1,849.00 $1,246.00 $821.00 $1,256.00 $1,122.00 $1,295.00 $543.00 $547.00 $1,727.00 $1,880.00 $2,553.00 $2,543.00 $1,384.00 $1,661.00 $1,632.00 $1,436.00 $1,023.00 $1,021.00 $918.00 $181.00

$3,487.00 $3,157.00 $3,158.00 $3,018.00 $2,991.00 $2,567.00 $2,706.00 $3,570.00 $3,520.00 $3,306.00 $3,188.00 $4,464.00 $4,385.00 $4,707.00 $4,660.00 $574.00 $3,067.00 $3,749.00 $3,684.00 $3,930.00 $3,944.00 $4,073.00 $3,764.00 $3,813.00 $547.00 $1,380.00 $647.00 $1,512.00 $1,891.00 $439.00 $1,968.00 $1,352.00 $874.00 $1,364.00 $1,190.00 $1,404.00 $581.00 $584.00 $1,845.00 $2,004.00 $2,800.00 $2,736.00 $1,499.00 $1,798.00 $1,765.00 $1,566.00 $1,112.00 $1,113.00 $1,004.00 $193.00

$3,943.00 $3,547.00 $3,577.00 $3,399.00 $3,366.00 $2,865.00 $3,066.00 $4,039.00 $3,977.00 $3,728.00 $3,601.00 $5,075.00 $4,974.00 $5,359.00 $5,268.00 $658.00 $3,442.00 $4,257.00 $4,176.00 $4,467.00 $4,460.00 $4,586.00 $4,150.00 $4,242.00 $619.00 $1,438.00 $674.00 $1,606.00 $2,138.00 $503.00 $1,999.00 $1,495.00 $904.00 $1,508.00 $1,230.00 $1,552.00 $626.00 $629.00 $1,989.00 $2,152.00 $3,165.00 $2,994.00 $1,654.00 $1,987.00 $1,947.00 $1,750.00 $1,233.00 $1,240.00 $1,124.00 $202.00

$3,187.00 $2,894.00 $2,881.00 $2,762.00 $2,739.00 $2,361.00 $2,466.00 $3,260.00 $3,217.00 $3,024.00 $2,912.00 $4,068.00 $4,000.00 $4,286.00 $4,261.00 $523.00 $2,813.00 $3,417.00 $3,360.00 $3,582.00 $3,604.00 $3,733.00 $3,490.00 $3,517.00 $502.00 $1,317.00 $623.00 $1,435.00 $1,726.00 $399.00 $600.00 $1,246.00 $470.00 $1,256.00 $663.00 $1,295.00 $543.00 $547.00 $1,727.00 $1,880.00 $2,553.00 $2,543.00 $1,384.00 $1,661.00 $1,632.00 $1,436.00 $1,023.00 $1,021.00 $918.00 $104.00

$3,487.00 $3,157.00 $3,158.00 $3,018.00 $2,991.00 $2,567.00 $2,706.00 $3,570.00 $3,520.00 $3,306.00 $3,188.00 $4,464.00 $4,385.00 $4,707.00 $4,660.00 $574.00 $3,067.00 $3,749.00 $3,684.00 $3,930.00 $3,944.00 $4,073.00 $3,764.00 $3,813.00 $547.00 $1,380.00 $647.00 $1,512.00 $1,891.00 $439.00 $628.00 $1,352.00 $497.00 $1,364.00 $697.00 $1,404.00 $581.00 $584.00 $1,845.00 $2,004.00 $2,800.00 $2,736.00 $1,499.00 $1,798.00 $1,765.00 $1,566.00 $1,112.00 $1,113.00 $1,004.00 $111.00

$3,943.00 $3,547.00 $3,577.00 $3,399.00 $3,366.00 $2,865.00 $3,066.00 $4,039.00 $3,977.00 $3,728.00 $3,601.00 $5,075.00 $4,974.00 $5,359.00 $5,268.00 $658.00 $3,442.00 $4,257.00 $4,176.00 $4,467.00 $4,460.00 $4,586.00 $4,150.00 $4,242.00 $619.00 $1,438.00 $674.00 $1,606.00 $2,138.00 $503.00 $655.00 $1,495.00 $527.00 $1,508.00 $735.00 $1,552.00 $626.00 $629.00 $1,989.00 $2,152.00 $3,165.00 $2,994.00 $1,654.00 $1,987.00 $1,947.00 $1,750.00 $1,233.00 $1,240.00 $1,124.00 $120.00


Part B, 264



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 ZZZ 0 ZZZ 0 0 0 0 0 ZZZ ZZZ 0 ZZZ ZZZ 0 0 0 0 0 0 0 10 10 10 10 0

$75.00 $103.00 $120.00 $109.00 $128.00 $109.00 $159.00 $105.00 $108.00 $89.00 $128.00 $116.00 $130.00 $114.00 $68.00 $165.00 $77.00 $152.00 -------$53.00 ----------------------------$224.00 $194.00 $206.00 $183.00 ----------------------------------------------------------------------$104.00 $99.00 $103.00 -------$131.00 $135.00 $23.00 $137.00 $131.00 $801.00 $121.00 --------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$186.00 $144.00 $145.00 $172.00 $180.00 $167.00 $115.00 $182.00 $204.00 $158.00 $212.00 $188.00 $195.00 $192.00 $192.00 $115.00 $169.00 $104.00 $123.00 $112.00 $68.00 $209.00 $119.00 $227.00 $332.00 $159.00 $308.00 $124.00 $175.00 $215.00 $216.00 $299.00 $268.00 $133.00 $134.00 $243.00 $122.00 $123.00 $149.00 $90.00 $178.00 $257.00 $260.00 $267.00 $22.00 $295.00 $298.00 $1,139.00 $267.00 $176.00

$199.00 $154.00 $152.00 $181.00 $191.00 $175.00 $119.00 $192.00 $217.00 $167.00 $224.00 $198.00 $206.00 $203.00 $203.00 $119.00 $178.00 $107.00 $128.00 $118.00 $71.00 $221.00 $125.00 $239.00 $350.00 $168.00 $326.00 $130.00 $185.00 $228.00 $229.00 $317.00 $283.00 $140.00 $141.00 $257.00 $129.00 $130.00 $157.00 $95.00 $188.00 $270.00 $276.00 $282.00 $23.00 $311.00 $315.00 $1,212.00 $283.00 $187.00

$209.00 $161.00 $157.00 $186.00 $198.00 $180.00 $124.00 $198.00 $222.00 $172.00 $230.00 $205.00 $213.00 $210.00 $210.00 $125.00 $183.00 $112.00 $134.00 $121.00 $74.00 $227.00 $129.00 $245.00 $359.00 $173.00 $333.00 $134.00 $190.00 $234.00 $235.00 $325.00 $290.00 $144.00 $145.00 $263.00 $133.00 $133.00 $163.00 $101.00 $193.00 $278.00 $281.00 $288.00 $24.00 $320.00 $325.00 $1,239.00 $293.00 $191.00

$116.00 $93.00 $108.00 $101.00 $118.00 $95.00 $115.00 $103.00 $111.00 $99.00 $133.00 $136.00 $119.00 $121.00 $106.00 $115.00 $97.00 $104.00 $123.00 $66.00 $51.00 $126.00 $80.00 $122.00 $191.00 $92.00 $163.00 $76.00 $92.00 $108.00 $117.00 $131.00 $154.00 $88.00 $89.00 $132.00 $76.00 $77.00 $126.00 $106.00 $106.00 $177.00 $117.00 $133.00 $13.00 $224.00 $221.00 $440.00 $190.00 $45.00

$124.00 $99.00 $112.00 $105.00 $125.00 $98.00 $119.00 $108.00 $116.00 $103.00 $139.00 $142.00 $125.00 $127.00 $111.00 $119.00 $100.00 $107.00 $128.00 $69.00 $53.00 $131.00 $83.00 $127.00 $200.00 $96.00 $170.00 $79.00 $96.00 $113.00 $122.00 $137.00 $161.00 $92.00 $93.00 $138.00 $79.00 $80.00 $132.00 $112.00 $111.00 $184.00 $122.00 $139.00 $13.00 $235.00 $232.00 $462.00 $200.00 $47.00

$134.00 $107.00 $117.00 $109.00 $132.00 $103.00 $124.00 $113.00 $121.00 $108.00 $144.00 $149.00 $131.00 $134.00 $117.00 $125.00 $105.00 $112.00 $134.00 $72.00 $55.00 $138.00 $87.00 $132.00 $208.00 $100.00 $177.00 $82.00 $101.00 $119.00 $128.00 $144.00 $168.00 $95.00 $97.00 $144.00 $83.00 $84.00 $138.00 $118.00 $115.00 $191.00 $127.00 $144.00 $13.00 $243.00 $242.00 $486.00 $210.00 $50.00


Part B, 265



90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 ZZZ 10 ZZZ 10 0 ZZZ 0 ZZZ 0 0 0 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90

---------------------$367.00 $343.00 $745.00 $37.00 $217.00 $153.00 $228.00 $319.00 $307.00 -------$188.00 ---------------------$185.00 $202.00 -----------------------------------$208.00 --------------------------------------------------------$180.00 -------$383.00 $402.00 $562.00 $678.00 $867.00 $715.00 $523.00 $558.00 $446.00 $439.00 $411.00 $271.00 $261.00 $405.00 $432.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$988.00 $1,183.00 $977.00 $466.00 $446.00 $967.00 $344.00 $373.00 $344.00 $554.00 $1,082.00 $1,085.00 $170.00 $190.00 $214.00 $186.00 $284.00 $290.00 $334.00 $121.00 $594.00 $265.00 $587.00 $241.00 $187.00 $205.00 $135.00 $235.00 $166.00 $218.00 $258.00 $110.00 $139.00 $434.00 $483.00 $720.00 $457.00 $721.00 $838.00 $1,066.00 $933.00 $779.00 $858.00 $580.00 $620.00 $538.00 $394.00 $274.00 $544.00 $598.00

$1,071.00 $1,283.00 $1,057.00 $497.00 $478.00 $1,014.00 $365.00 $396.00 $366.00 $592.00 $1,173.00 $1,175.00 $185.00 $203.00 $232.00 $202.00 $307.00 $304.00 $354.00 $126.00 $628.00 $282.00 $620.00 $256.00 $197.00 $220.00 $144.00 $251.00 $178.00 $234.00 $277.00 $117.00 $150.00 $460.00 $509.00 $766.00 $481.00 $769.00 $893.00 $1,134.00 $985.00 $828.00 $916.00 $619.00 $663.00 $574.00 $413.00 $293.00 $579.00 $634.00

$1,183.00 $1,423.00 $1,166.00 $531.00 $518.00 $1,071.00 $376.00 $408.00 $375.00 $617.00 $1,259.00 $1,271.00 $200.00 $216.00 $257.00 $222.00 $330.00 $314.00 $372.00 $130.00 $641.00 $286.00 $633.00 $260.00 $202.00 $235.00 $155.00 $268.00 $190.00 $251.00 $297.00 $122.00 $160.00 $471.00 $521.00 $809.00 $501.00 $817.00 $954.00 $1,218.00 $1,042.00 $875.00 $975.00 $658.00 $704.00 $611.00 $428.00 $318.00 $615.00 $667.00

$988.00 $1,183.00 $977.00 $466.00 $446.00 $967.00 $207.00 $232.00 $182.00 $322.00 $625.00 $742.00 $150.00 $171.00 $188.00 $164.00 $187.00 $247.00 $281.00 $99.00 $328.00 $100.00 $323.00 $87.00 $133.00 $161.00 $108.00 $176.00 $124.00 $174.00 $203.00 $62.00 $82.00 $240.00 $276.00 $720.00 $457.00 $721.00 $838.00 $1,066.00 $933.00 $779.00 $858.00 $580.00 $617.00 $538.00 $394.00 $274.00 $544.00 $598.00

$1,071.00 $1,283.00 $1,057.00 $497.00 $478.00 $1,014.00 $218.00 $245.00 $193.00 $343.00 $682.00 $807.00 $164.00 $183.00 $204.00 $178.00 $203.00 $258.00 $298.00 $103.00 $343.00 $104.00 $338.00 $91.00 $139.00 $172.00 $116.00 $188.00 $133.00 $187.00 $218.00 $66.00 $88.00 $252.00 $287.00 $766.00 $481.00 $769.00 $893.00 $1,134.00 $985.00 $828.00 $916.00 $619.00 $659.00 $574.00 $413.00 $293.00 $579.00 $634.00

$1,183.00 $1,423.00 $1,166.00 $531.00 $518.00 $1,071.00 $228.00 $257.00 $202.00 $367.00 $767.00 $902.00 $179.00 $195.00 $229.00 $198.00 $226.00 $268.00 $316.00 $106.00 $355.00 $108.00 $350.00 $94.00 $144.00 $187.00 $126.00 $205.00 $146.00 $203.00 $238.00 $71.00 $98.00 $262.00 $299.00 $809.00 $501.00 $817.00 $954.00 $1,218.00 $1,042.00 $875.00 $975.00 $658.00 $700.00 $611.00 $428.00 $318.00 $615.00 $667.00


Part B, 266



90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 90 ZZZ

$388.00 $475.00 $461.00 $517.00 $798.00 $494.00 $1,042.00 $578.00 $561.00 $713.00 $632.00 $636.00 $392.00 $390.00 $249.00 $482.00 $298.00 $751.00 $1,281.00 $458.00 $381.00 $884.00 $1,148.00 $247.00 $711.00 $1,202.00 $1,080.00 $845.00 $838.00 $609.00 $609.00 $703.00 $592.00 $171.00 $711.00 $834.00 $856.00 $480.00 $1,058.00 $1,063.00 $1,137.00 $1,313.00 $341.00 $1,524.00 $1,798.00 $970.00 $1,250.00 $1,238.00 $1,162.00 $155.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$576.00 $615.00 $662.00 $695.00 $740.00 $668.00 $1,379.00 $746.00 $747.00 $877.00 $870.00 $821.00 $607.00 $567.00 $209.00 $656.00 $325.00 $1,067.00 $1,580.00 $358.00 $584.00 $1,246.00 $1,832.00 $289.00 $967.00 $1,512.00 $1,539.00 $903.00 $1,054.00 $996.00 $996.00 $1,136.00 $995.00 $499.00 $1,081.00 $1,184.00 $1,188.00 $548.00 $1,512.00 $1,491.00 $1,546.00 $1,663.00 $372.00 $1,961.00 $2,359.00 $1,286.00 $1,646.00 $1,678.00 $1,482.00 $178.00

$612.00 $650.00 $702.00 $730.00 $808.00 $719.00 $1,481.00 $797.00 $798.00 $927.00 $926.00 $877.00 $647.00 $601.00 $217.00 $692.00 $344.00 $1,135.00 $1,687.00 $379.00 $625.00 $1,340.00 $2,007.00 $311.00 $1,018.00 $1,638.00 $1,674.00 $952.00 $1,117.00 $1,058.00 $1,058.00 $1,205.00 $1,060.00 $530.00 $1,150.00 $1,263.00 $1,268.00 $580.00 $1,633.00 $1,590.00 $1,646.00 $1,767.00 $394.00 $2,094.00 $2,588.00 $1,362.00 $1,747.00 $1,776.00 $1,570.00 $189.00

$646.00 $686.00 $737.00 $754.00 $899.00 $785.00 $1,625.00 $862.00 $862.00 $981.00 $983.00 $941.00 $690.00 $634.00 $226.00 $728.00 $367.00 $1,211.00 $1,817.00 $405.00 $670.00 $1,462.00 $2,264.00 $342.00 $1,069.00 $1,827.00 $1,870.00 $1,015.00 $1,184.00 $1,117.00 $1,117.00 $1,276.00 $1,126.00 $570.00 $1,225.00 $1,355.00 $1,360.00 $619.00 $1,793.00 $1,709.00 $1,762.00 $1,890.00 $421.00 $2,266.00 $2,932.00 $1,444.00 $1,850.00 $1,872.00 $1,661.00 $203.00

$576.00 $615.00 $662.00 $695.00 $740.00 $668.00 $1,379.00 $746.00 $747.00 $877.00 $870.00 $821.00 $607.00 $567.00 $209.00 $656.00 $325.00 $1,067.00 $1,580.00 $358.00 $584.00 $1,246.00 $1,832.00 $289.00 $967.00 $1,512.00 $1,539.00 $903.00 $1,054.00 $996.00 $996.00 $1,136.00 $995.00 $499.00 $1,081.00 $1,184.00 $1,188.00 $548.00 $1,512.00 $1,491.00 $1,546.00 $1,663.00 $372.00 $1,961.00 $2,359.00 $1,286.00 $1,646.00 $1,678.00 $1,482.00 $178.00

$612.00 $650.00 $702.00 $730.00 $808.00 $719.00 $1,481.00 $797.00 $798.00 $927.00 $926.00 $877.00 $647.00 $601.00 $217.00 $692.00 $344.00 $1,135.00 $1,687.00 $379.00 $625.00 $1,340.00 $2,007.00 $311.00 $1,018.00 $1,638.00 $1,674.00 $952.00 $1,117.00 $1,058.00 $1,058.00 $1,205.00 $1,060.00 $530.00 $1,150.00 $1,263.00 $1,268.00 $580.00 $1,633.00 $1,590.00 $1,646.00 $1,767.00 $394.00 $2,094.00 $2,588.00 $1,362.00 $1,747.00 $1,776.00 $1,570.00 $189.00

$646.00 $686.00 $737.00 $754.00 $899.00 $785.00 $1,625.00 $862.00 $862.00 $981.00 $983.00 $941.00 $690.00 $634.00 $226.00 $728.00 $367.00 $1,211.00 $1,817.00 $405.00 $670.00 $1,462.00 $2,264.00 $342.00 $1,069.00 $1,827.00 $1,870.00 $1,015.00 $1,184.00 $1,117.00 $1,117.00 $1,276.00 $1,126.00 $570.00 $1,225.00 $1,355.00 $1,360.00 $619.00 $1,793.00 $1,709.00 $1,762.00 $1,890.00 $421.00 $2,266.00 $2,932.00 $1,444.00 $1,850.00 $1,872.00 $1,661.00 $203.00


Part B, 267



ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 10 90 90 90 90 90 90 90 90

$230.00 $189.00 $1,382.00 $1,636.00 $1,112.00 $1,243.00 $1,177.00 $1,321.00 $1,500.00 $1,185.00 $1,419.00 $1,549.00 $865.00 $982.00 $1,059.00 $1,472.00 --------------BR $678.00 $712.00 $726.00 $769.00 $846.00 $1,305.00 $1,386.00 $1,456.00 $312.00 $730.00 $678.00 $738.00 $652.00 $862.00 $654.00 $45.00 $53.00 $58.00 $62.00 $627.00 $956.00 $1,104.00 $88.00 $223.00 $376.00 $75.00 $711.00 $1,177.00 $692.00 $519.00 $603.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$255.00 $261.00 $1,684.00 $1,910.00 $1,593.00 $1,705.00 $1,525.00 $1,658.00 $1,969.00 $2,099.00 $1,814.00 $2,016.00 $825.00 $973.00 $1,504.00 $2,067.00 $1,201.00 $1,473.00 -------$888.00 $878.00 $1,031.00 $1,077.00 $1,188.00 $1,719.00 $2,001.00 $2,102.00 $633.00 $1,023.00 $1,039.00 $1,129.00 $799.00 $1,184.00 $919.00 $78.00 $96.00 $82.00 $93.00 $999.00 $1,350.00 $1,522.00 $369.00 $698.00 $537.00 $807.00 $945.00 $1,562.00 $979.00 $688.00 $950.00

$271.00 $275.00 $1,787.00 $2,021.00 $1,691.00 $1,811.00 $1,618.00 $1,761.00 $2,100.00 $2,225.00 $1,918.00 $2,153.00 $870.00 $1,028.00 $1,600.00 $2,240.00 $1,278.00 $1,564.00 -------$934.00 $924.00 $1,085.00 $1,133.00 $1,249.00 $1,806.00 $2,103.00 $2,209.00 $671.00 $1,076.00 $1,092.00 $1,188.00 $841.00 $1,245.00 $967.00 $82.00 $101.00 $86.00 $98.00 $1,049.00 $1,416.00 $1,596.00 $391.00 $737.00 $563.00 $850.00 $991.00 $1,637.00 $1,033.00 $722.00 $1,000.00

$292.00 $293.00 $1,901.00 $2,145.00 $1,797.00 $1,928.00 $1,719.00 $1,873.00 $2,259.00 $2,364.00 $2,030.00 $2,324.00 $927.00 $1,098.00 $1,706.00 $2,484.00 $1,359.00 $1,658.00 -------$956.00 $946.00 $1,110.00 $1,159.00 $1,280.00 $1,857.00 $2,168.00 $2,277.00 $683.00 $1,101.00 $1,119.00 $1,216.00 $860.00 $1,275.00 $990.00 $84.00 $103.00 $90.00 $100.00 $1,076.00 $1,454.00 $1,640.00 $398.00 $752.00 $578.00 $869.00 $1,018.00 $1,683.00 $1,054.00 $742.00 $1,023.00

$255.00 $261.00 $1,684.00 $1,910.00 $1,593.00 $1,705.00 $1,525.00 $1,658.00 $1,969.00 $2,099.00 $1,814.00 $2,016.00 $825.00 $973.00 $1,504.00 $2,067.00 $1,201.00 $1,473.00 -------$888.00 $878.00 $1,031.00 $1,077.00 $1,188.00 $1,719.00 $2,001.00 $2,102.00 $410.00 $1,023.00 $1,039.00 $1,129.00 $799.00 $1,184.00 $919.00 $62.00 $75.00 $61.00 $74.00 $999.00 $1,350.00 $1,522.00 $198.00 $494.00 $537.00 $651.00 $945.00 $1,562.00 $698.00 $688.00 $847.00

$271.00 $275.00 $1,787.00 $2,021.00 $1,691.00 $1,811.00 $1,618.00 $1,761.00 $2,100.00 $2,225.00 $1,918.00 $2,153.00 $870.00 $1,028.00 $1,600.00 $2,240.00 $1,278.00 $1,564.00 -------$934.00 $924.00 $1,085.00 $1,133.00 $1,249.00 $1,806.00 $2,103.00 $2,209.00 $432.00 $1,076.00 $1,092.00 $1,188.00 $841.00 $1,245.00 $967.00 $65.00 $78.00 $64.00 $77.00 $1,049.00 $1,416.00 $1,596.00 $208.00 $518.00 $563.00 $683.00 $991.00 $1,637.00 $732.00 $722.00 $890.00

$292.00 $293.00 $1,901.00 $2,145.00 $1,797.00 $1,928.00 $1,719.00 $1,873.00 $2,259.00 $2,364.00 $2,030.00 $2,324.00 $927.00 $1,098.00 $1,706.00 $2,484.00 $1,359.00 $1,658.00 -------$956.00 $946.00 $1,110.00 $1,159.00 $1,280.00 $1,857.00 $2,168.00 $2,277.00 $443.00 $1,101.00 $1,119.00 $1,216.00 $860.00 $1,275.00 $990.00 $66.00 $80.00 $67.00 $79.00 $1,076.00 $1,454.00 $1,640.00 $214.00 $532.00 $578.00 $702.00 $1,018.00 $1,683.00 $752.00 $742.00 $913.00


Part B, 268



0 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 0 90 90 90 90 10 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90

$142.00 $448.00 $534.00 $81.00 $88.00 $319.00 $52.00 $325.00 $1,124.00 $1,314.00 $1,381.00 $1,373.00 -------$1,461.00 $449.00 $595.00 ------------------------------------------$88.00 $516.00 $327.00 $813.00 $968.00 $441.00 $339.00 $540.00 $572.00 $597.00 $641.00 $945.00 $752.00 $700.00 $164.00 $160.00 $631.00 $798.00 $795.00 $942.00 $1,089.00 $1,264.00 ---------------------$1,313.00 ---------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$199.00 $716.00 $906.00 $160.00 $111.00 $544.00 $454.00 $550.00 $1,555.00 $1,726.00 $1,737.00 $1,728.00 $1,671.00 $1,979.00 $631.00 $774.00 $1,954.00 $1,643.00 $1,006.00 $1,877.00 $1,619.00 $2,905.00 $167.00 $654.00 $887.00 $1,050.00 $1,182.00 $381.00 $432.00 $663.00 $829.00 $884.00 $929.00 $1,349.00 $1,108.00 $896.00 $259.00 $230.00 $972.00 $1,229.00 $1,228.00 $1,386.00 $1,360.00 $1,709.00 $1,334.00 $1,398.00 $1,514.00 $1,599.00 $1,447.00 $1,101.00

$210.00 $757.00 $957.00 $168.00 $117.00 $571.00 $478.00 $580.00 $1,632.00 $1,810.00 $1,821.00 $1,811.00 $1,750.00 $2,073.00 $664.00 $813.00 $2,094.00 $1,757.00 $1,059.00 $1,968.00 $1,698.00 $3,108.00 $175.00 $686.00 $936.00 $1,103.00 $1,239.00 $402.00 $454.00 $697.00 $871.00 $929.00 $975.00 $1,415.00 $1,163.00 $940.00 $274.00 $243.00 $1,023.00 $1,292.00 $1,291.00 $1,456.00 $1,430.00 $1,802.00 $1,398.00 $1,465.00 $1,589.00 $1,678.00 $1,519.00 $1,157.00

$215.00 $771.00 $976.00 $172.00 $119.00 $586.00 $489.00 $592.00 $1,675.00 $1,859.00 $1,871.00 $1,861.00 $1,800.00 $2,132.00 $679.00 $834.00 $2,103.00 $1,769.00 $1,083.00 $2,022.00 $1,744.00 $3,145.00 $180.00 $704.00 $955.00 $1,130.00 $1,273.00 $410.00 $465.00 $714.00 $893.00 $952.00 $1,001.00 $1,452.00 $1,193.00 $965.00 $279.00 $247.00 $1,047.00 $1,323.00 $1,322.00 $1,493.00 $1,464.00 $1,841.00 $1,437.00 $1,505.00 $1,631.00 $1,723.00 $1,559.00 $1,186.00

$147.00 $529.00 $672.00 $146.00 $98.00 $523.00 $450.00 $483.00 $1,555.00 $1,726.00 $1,737.00 $1,728.00 $1,671.00 $1,979.00 $571.00 $774.00 $83.00 $216.00 $1,006.00 $1,877.00 $1,619.00 $555.00 $130.00 $654.00 $671.00 $1,050.00 $1,182.00 $336.00 $357.00 $663.00 $829.00 $884.00 $929.00 $1,349.00 $1,108.00 $896.00 $185.00 $155.00 $801.00 $1,229.00 $1,228.00 $1,386.00 $1,360.00 $1,709.00 $1,334.00 $1,398.00 $1,514.00 $1,599.00 $1,447.00 $1,101.00

$154.00 $557.00 $706.00 $152.00 $102.00 $549.00 $474.00 $507.00 $1,632.00 $1,810.00 $1,821.00 $1,811.00 $1,750.00 $2,073.00 $600.00 $813.00 $87.00 $225.00 $1,059.00 $1,968.00 $1,698.00 $587.00 $136.00 $686.00 $705.00 $1,103.00 $1,239.00 $354.00 $374.00 $697.00 $871.00 $929.00 $975.00 $1,415.00 $1,163.00 $940.00 $194.00 $164.00 $840.00 $1,292.00 $1,291.00 $1,456.00 $1,430.00 $1,802.00 $1,398.00 $1,465.00 $1,589.00 $1,678.00 $1,519.00 $1,157.00

$159.00 $570.00 $724.00 $157.00 $105.00 $563.00 $485.00 $520.00 $1,675.00 $1,859.00 $1,871.00 $1,861.00 $1,800.00 $2,132.00 $615.00 $834.00 $89.00 $233.00 $1,083.00 $2,022.00 $1,744.00 $616.00 $140.00 $704.00 $723.00 $1,130.00 $1,273.00 $362.00 $385.00 $714.00 $893.00 $952.00 $1,001.00 $1,452.00 $1,193.00 $965.00 $199.00 $168.00 $864.00 $1,323.00 $1,322.00 $1,493.00 $1,464.00 $1,841.00 $1,437.00 $1,505.00 $1,631.00 $1,723.00 $1,559.00 $1,186.00


Part B, 269



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ YYY 90 90 90 90 90 0 90 90 90 90 90 90

$769.00 $711.00 $1,006.00 $602.00 $359.00 $359.00 $825.00 $1,136.00 $543.00 $623.00 $595.00 $526.00 $627.00 $506.00 $513.00 -------$506.00 $473.00 $506.00 $433.00 $483.00 $433.00 $275.00 $753.00 $651.00 $707.00 $805.00 $878.00 $785.00 $906.00 $819.00 $846.00 $763.00 $898.00 $744.00 $1,038.00 $84.00 BR $639.00 $647.00 $637.00 $774.00 $1,089.00 $338.00 $485.00 $402.00 $1,384.00 $1,490.00 $1,960.00 --------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,186.00 $1,047.00 $1,311.00 $1,042.00 $494.00 $542.00 $1,166.00 $1,487.00 $603.00 $800.00 $808.00 $727.00 $892.00 $629.00 $616.00 $901.00 $662.00 $612.00 $413.00 $664.00 $738.00 $548.00 $460.00 $1,065.00 $1,001.00 $980.00 $1,115.00 $1,189.00 $1,061.00 $1,206.00 $1,101.00 $1,120.00 $1,039.00 $899.00 $1,082.00 $1,279.00 $129.00 -------$664.00 $763.00 $814.00 $1,015.00 $1,201.00 $144.00 $745.00 $544.00 $1,269.00 $1,360.00 $1,470.00 $1,626.00

$1,246.00 $1,100.00 $1,375.00 $1,100.00 $521.00 $571.00 $1,226.00 $1,559.00 $633.00 $840.00 $848.00 $763.00 $939.00 $662.00 $647.00 $946.00 $698.00 $644.00 $436.00 $699.00 $777.00 $578.00 $485.00 $1,120.00 $1,050.00 $1,028.00 $1,170.00 $1,246.00 $1,113.00 $1,265.00 $1,155.00 $1,174.00 $1,086.00 $943.00 $1,136.00 $1,341.00 $134.00 -------$697.00 $801.00 $855.00 $1,068.00 $1,259.00 $151.00 $784.00 $572.00 $1,331.00 $1,425.00 $1,541.00 $1,703.00

$1,278.00 $1,128.00 $1,413.00 $1,122.00 $532.00 $584.00 $1,257.00 $1,602.00 $649.00 $861.00 $870.00 $783.00 $961.00 $678.00 $663.00 $970.00 $714.00 $659.00 $445.00 $715.00 $795.00 $590.00 $496.00 $1,147.00 $1,078.00 $1,055.00 $1,201.00 $1,280.00 $1,143.00 $1,300.00 $1,186.00 $1,206.00 $1,112.00 $968.00 $1,165.00 $1,377.00 $139.00 -------$715.00 $822.00 $876.00 $1,093.00 $1,293.00 $155.00 $803.00 $586.00 $1,367.00 $1,464.00 $1,584.00 $1,751.00

$1,186.00 $1,047.00 $1,311.00 $783.00 $494.00 $542.00 $1,166.00 $1,487.00 $603.00 $800.00 $808.00 $727.00 $892.00 $553.00 $552.00 $901.00 $594.00 $553.00 $332.00 $599.00 $680.00 $548.00 $435.00 $1,065.00 $1,001.00 $980.00 $1,115.00 $1,189.00 $1,061.00 $1,206.00 $1,101.00 $1,120.00 $1,039.00 $899.00 $1,082.00 $1,279.00 $129.00 -------$664.00 $763.00 $814.00 $889.00 $1,201.00 $142.00 $745.00 $501.00 $1,269.00 $1,360.00 $1,470.00 $1,626.00

$1,246.00 $1,100.00 $1,375.00 $822.00 $521.00 $571.00 $1,226.00 $1,559.00 $633.00 $840.00 $848.00 $763.00 $939.00 $580.00 $580.00 $946.00 $625.00 $580.00 $348.00 $629.00 $714.00 $578.00 $458.00 $1,120.00 $1,050.00 $1,028.00 $1,170.00 $1,246.00 $1,113.00 $1,265.00 $1,155.00 $1,174.00 $1,086.00 $943.00 $1,136.00 $1,341.00 $134.00 -------$697.00 $801.00 $855.00 $933.00 $1,259.00 $148.00 $784.00 $527.00 $1,331.00 $1,425.00 $1,541.00 $1,703.00

$1,278.00 $1,128.00 $1,413.00 $844.00 $532.00 $584.00 $1,257.00 $1,602.00 $649.00 $861.00 $870.00 $783.00 $961.00 $595.00 $595.00 $970.00 $641.00 $595.00 $358.00 $645.00 $732.00 $590.00 $469.00 $1,147.00 $1,078.00 $1,055.00 $1,201.00 $1,280.00 $1,143.00 $1,300.00 $1,186.00 $1,206.00 $1,112.00 $968.00 $1,165.00 $1,377.00 $139.00 -------$715.00 $822.00 $876.00 $958.00 $1,293.00 $153.00 $803.00 $540.00 $1,367.00 $1,464.00 $1,584.00 $1,751.00


Part B, 270



90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 10 10 90 90 90 YYY 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 10 0 YYY 90 90 90 90 90 0 90 90 90 90

--------------$767.00 $941.00 $1,350.00 $1,878.00 $1,040.00 -------$496.00 $751.00 $962.00 $536.00 $514.00 $655.00 $779.00 $1,217.00 $894.00 $325.00 $44.00 $652.00 $1,025.00 -------$793.00 $872.00 BR $616.00 $773.00 $688.00 $857.00 $663.00 $602.00 $560.00 $621.00 $447.00 $253.00 $559.00 $628.00 $275.00 -------BR $960.00 $799.00 $976.00 $909.00 $1,023.00 $146.00 $1,729.00 $1,203.00 $1,257.00 $1,269.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,626.00 $1,717.00 $1,095.00 $1,007.00 $1,433.00 $1,819.00 $1,063.00 $1,985.00 $701.00 $917.00 $1,279.00 $733.00 $738.00 $841.00 $726.00 $1,954.00 $748.00 $402.00 $42.00 $406.00 $478.00 $1,584.00 $1,095.00 $958.00 -------$841.00 $1,003.00 $947.00 $1,128.00 $990.00 $459.00 $436.00 $473.00 $430.00 $211.00 $511.00 $919.00 $345.00 $275.00 -------$1,304.00 $1,115.00 $1,193.00 $1,201.00 $1,867.00 $149.00 $2,283.00 $1,741.00 $1,692.00 $1,976.00

$1,703.00 $1,798.00 $1,153.00 $1,059.00 $1,502.00 $1,913.00 $1,119.00 $2,082.00 $737.00 $966.00 $1,341.00 $771.00 $776.00 $883.00 $763.00 $2,045.00 $786.00 $422.00 $44.00 $426.00 $502.00 $1,664.00 $1,151.00 $1,007.00 -------$882.00 $1,051.00 $993.00 $1,183.00 $1,038.00 $479.00 $455.00 $493.00 $448.00 $220.00 $533.00 $965.00 $366.00 $288.00 -------$1,371.00 $1,174.00 $1,255.00 $1,264.00 $1,959.00 $155.00 $2,399.00 $1,831.00 $1,781.00 $2,074.00

$1,752.00 $1,850.00 $1,180.00 $1,084.00 $1,544.00 $1,959.00 $1,145.00 $2,139.00 $755.00 $988.00 $1,377.00 $790.00 $795.00 $906.00 $782.00 $2,105.00 $805.00 $432.00 $45.00 $437.00 $515.00 $1,728.00 $1,180.00 $1,032.00 -------$906.00 $1,080.00 $1,020.00 $1,216.00 $1,066.00 $495.00 $470.00 $510.00 $463.00 $228.00 $550.00 $991.00 $382.00 $298.00 -------$1,406.00 $1,206.00 $1,288.00 $1,299.00 $2,017.00 $160.00 $2,475.00 $1,881.00 $1,833.00 $2,137.00

$1,626.00 $1,717.00 $948.00 $906.00 $1,433.00 $1,819.00 $977.00 $1,985.00 $701.00 $784.00 $1,279.00 $685.00 $700.00 $814.00 $703.00 $1,954.00 $703.00 $303.00 $39.00 $362.00 $434.00 $1,584.00 $1,095.00 $958.00 -------$841.00 $1,003.00 $947.00 $1,128.00 $990.00 $459.00 $436.00 $473.00 $430.00 $211.00 $511.00 $919.00 $312.00 $275.00 -------$1,304.00 $1,115.00 $1,193.00 $1,201.00 $1,867.00 $149.00 $2,283.00 $1,741.00 $1,692.00 $1,976.00

$1,703.00 $1,798.00 $994.00 $950.00 $1,502.00 $1,913.00 $1,027.00 $2,082.00 $737.00 $823.00 $1,341.00 $720.00 $735.00 $854.00 $738.00 $2,045.00 $738.00 $316.00 $41.00 $379.00 $454.00 $1,664.00 $1,151.00 $1,007.00 -------$882.00 $1,051.00 $993.00 $1,183.00 $1,038.00 $479.00 $455.00 $493.00 $448.00 $220.00 $533.00 $965.00 $331.00 $288.00 -------$1,371.00 $1,174.00 $1,255.00 $1,264.00 $1,959.00 $155.00 $2,399.00 $1,831.00 $1,781.00 $2,074.00

$1,752.00 $1,850.00 $1,021.00 $976.00 $1,544.00 $1,959.00 $1,052.00 $2,139.00 $755.00 $845.00 $1,377.00 $738.00 $754.00 $877.00 $757.00 $2,105.00 $757.00 $326.00 $42.00 $389.00 $467.00 $1,728.00 $1,180.00 $1,032.00 -------$906.00 $1,080.00 $1,020.00 $1,216.00 $1,066.00 $495.00 $470.00 $510.00 $463.00 $228.00 $550.00 $991.00 $347.00 $298.00 -------$1,406.00 $1,206.00 $1,288.00 $1,299.00 $2,017.00 $160.00 $2,475.00 $1,881.00 $1,833.00 $2,137.00


Part B, 271



90 0 0 0 90 90 90 YYY 10 10 10 10 10 10 90 0 0 10 10 90 10 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 10 90 90 90 90

$1,300.00 $75.00 $109.00 $53.00 $946.00 $936.00 $1,148.00 BR $87.00 $117.00 $102.00 $119.00 $189.00 $208.00 $308.00 $133.00 $36.00 $130.00 $239.00 $500.00 $187.00 $143.00 $163.00 $442.00 $643.00 $487.00 $646.00 $650.00 $657.00 $720.00 $633.00 $550.00 $577.00 $517.00 -------$487.00 $252.00 $675.00 $631.00 $419.00 $243.00 $718.00 $605.00 $280.00 $520.00 $67.00 $584.00 $571.00 $645.00 $875.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,764.00 $112.00 $125.00 $136.00 $1,353.00 $1,387.00 $1,646.00 -------$369.00 $307.00 $328.00 $177.00 $227.00 $282.00 $519.00 $239.00 $70.00 $179.00 $367.00 $616.00 $380.00 $298.00 $238.00 $639.00 $786.00 $895.00 $1,054.00 $1,021.00 $829.00 $1,022.00 $715.00 $688.00 $747.00 $792.00 $1,223.00 $650.00 $404.00 $823.00 $839.00 $636.00 $400.00 $821.00 $876.00 $507.00 $830.00 $333.00 $799.00 $800.00 $1,076.00 $1,021.00

$1,856.00 $116.00 $131.00 $143.00 $1,423.00 $1,459.00 $1,742.00 -------$392.00 $326.00 $349.00 $187.00 $238.00 $297.00 $545.00 $254.00 $73.00 $189.00 $390.00 $647.00 $403.00 $317.00 $252.00 $674.00 $828.00 $944.00 $1,112.00 $1,071.00 $873.00 $1,077.00 $750.00 $725.00 $788.00 $832.00 $1,298.00 $688.00 $428.00 $870.00 $885.00 $674.00 $424.00 $868.00 $925.00 $534.00 $876.00 $353.00 $843.00 $844.00 $1,132.00 $1,070.00

$1,911.00 $121.00 $135.00 $147.00 $1,460.00 $1,498.00 $1,815.00 -------$397.00 $330.00 $355.00 $191.00 $244.00 $304.00 $560.00 $261.00 $75.00 $193.00 $396.00 $664.00 $410.00 $325.00 $256.00 $689.00 $847.00 $969.00 $1,137.00 $1,104.00 $895.00 $1,104.00 $771.00 $742.00 $807.00 $855.00 $1,325.00 $701.00 $435.00 $888.00 $905.00 $685.00 $431.00 $885.00 $944.00 $546.00 $900.00 $357.00 $864.00 $863.00 $1,162.00 $1,102.00

$1,764.00 $103.00 $115.00 $126.00 $1,353.00 $1,387.00 $1,646.00 -------$164.00 $136.00 $153.00 $146.00 $189.00 $232.00 $519.00 $104.00 $75.00 $170.00 $195.00 $616.00 $223.00 $193.00 $137.00 $518.00 $664.00 $720.00 $813.00 $1,021.00 $682.00 $842.00 $715.00 $596.00 $617.00 $792.00 $694.00 $459.00 $277.00 $607.00 $645.00 $435.00 $276.00 $606.00 $645.00 $340.00 $627.00 $162.00 $653.00 $640.00 $928.00 $1,021.00

$1,856.00 $107.00 $120.00 $132.00 $1,423.00 $1,459.00 $1,742.00 -------$172.00 $144.00 $161.00 $153.00 $198.00 $244.00 $545.00 $109.00 $78.00 $179.00 $205.00 $647.00 $234.00 $204.00 $144.00 $544.00 $697.00 $756.00 $853.00 $1,071.00 $716.00 $884.00 $750.00 $627.00 $649.00 $832.00 $731.00 $483.00 $292.00 $638.00 $678.00 $458.00 $291.00 $636.00 $677.00 $356.00 $658.00 $170.00 $687.00 $672.00 $973.00 $1,070.00

$1,911.00 $112.00 $124.00 $136.00 $1,460.00 $1,498.00 $1,815.00 -------$177.00 $147.00 $166.00 $157.00 $203.00 $250.00 $560.00 $115.00 $80.00 $183.00 $210.00 $664.00 $241.00 $211.00 $149.00 $559.00 $716.00 $781.00 $878.00 $1,104.00 $737.00 $909.00 $771.00 $643.00 $667.00 $855.00 $757.00 $495.00 $298.00 $656.00 $696.00 $469.00 $298.00 $653.00 $696.00 $367.00 $681.00 $174.00 $707.00 $691.00 $1,002.00 $1,102.00


Part B, 272



90 90 90 YYY 10 0 0 10 10 90 10 0 90 90 90 90 90 90 90 90 90 10 YYY 10 10 10 90 90 0 90 0 10 90 90 90 10 90 90 90 10 10 90 10 10 10 10 10 10 0 YYY

$1,126.00 $1,140.00 $681.00 BR $106.00 $75.00 $137.00 $172.00 $248.00 $378.00 $146.00 $59.00 $502.00 $672.00 $654.00 $741.00 $488.00 $636.00 $413.00 $449.00 $691.00 -------BR $154.00 $191.00 $96.00 $882.00 $921.00 $491.00 $687.00 $340.00 $379.00 $875.00 $1,107.00 $628.00 $176.00 $807.00 $704.00 $792.00 $109.00 $130.00 $634.00 $202.00 $290.00 $191.00 $399.00 -------$100.00 $76.00 BR

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,314.00 $1,311.00 $965.00 -------$167.00 $88.00 $235.00 $312.00 $431.00 $748.00 $219.00 $58.00 $1,006.00 $928.00 $909.00 $998.00 $840.00 $911.00 $757.00 $740.00 $924.00 $580.00 -------$391.00 $445.00 $142.00 $1,371.00 $1,363.00 $621.00 $968.00 $376.00 $593.00 $1,309.00 $1,571.00 $850.00 $328.00 $1,065.00 $1,068.00 $1,106.00 $279.00 $205.00 $884.00 $139.00 $270.00 $233.00 $549.00 $882.00 $178.00 $86.00 --------

$1,377.00 $1,374.00 $1,013.00 -------$176.00 $92.00 $249.00 $330.00 $456.00 $790.00 $231.00 $61.00 $1,063.00 $974.00 $954.00 $1,047.00 $887.00 $956.00 $799.00 $782.00 $969.00 $609.00 -------$415.00 $471.00 $150.00 $1,439.00 $1,430.00 $655.00 $1,018.00 $392.00 $627.00 $1,375.00 $1,657.00 $892.00 $347.00 $1,118.00 $1,121.00 $1,162.00 $295.00 $216.00 $928.00 $147.00 $286.00 $246.00 $582.00 $941.00 $188.00 $91.00 --------

$1,417.00 $1,415.00 $1,042.00 -------$180.00 $94.00 $253.00 $336.00 $464.00 $806.00 $236.00 $63.00 $1,084.00 $1,002.00 $980.00 $1,077.00 $905.00 $981.00 $815.00 $799.00 $995.00 $624.00 -------$421.00 $480.00 $153.00 $1,477.00 $1,469.00 $669.00 $1,047.00 $406.00 $639.00 $1,413.00 $1,726.00 $916.00 $354.00 $1,149.00 $1,151.00 $1,194.00 $301.00 $220.00 $952.00 $149.00 $291.00 $251.00 $591.00 $950.00 $191.00 $93.00 --------

$1,314.00 $1,311.00 $965.00 -------$155.00 $72.00 $137.00 $209.00 $259.00 $579.00 $212.00 $49.00 $757.00 $928.00 $909.00 $998.00 $648.00 $911.00 $561.00 $580.00 $924.00 $580.00 -------$186.00 $238.00 $138.00 $1,371.00 $1,363.00 $415.00 $968.00 $376.00 $364.00 $1,309.00 $1,571.00 $850.00 $234.00 $1,065.00 $1,068.00 $1,106.00 $205.00 $167.00 $884.00 $121.00 $212.00 $233.00 $312.00 $283.00 $163.00 $79.00 --------

$1,377.00 $1,374.00 $1,013.00 -------$163.00 $75.00 $144.00 $219.00 $272.00 $608.00 $223.00 $52.00 $796.00 $974.00 $954.00 $1,047.00 $681.00 $956.00 $590.00 $610.00 $969.00 $609.00 -------$195.00 $250.00 $146.00 $1,439.00 $1,430.00 $434.00 $1,018.00 $392.00 $381.00 $1,375.00 $1,657.00 $892.00 $246.00 $1,118.00 $1,121.00 $1,162.00 $216.00 $175.00 $928.00 $127.00 $223.00 $246.00 $328.00 $298.00 $172.00 $83.00 --------

$1,417.00 $1,415.00 $1,042.00 -------$167.00 $77.00 $148.00 $224.00 $279.00 $623.00 $229.00 $53.00 $817.00 $1,002.00 $980.00 $1,077.00 $699.00 $981.00 $605.00 $627.00 $995.00 $624.00 -------$200.00 $257.00 $149.00 $1,477.00 $1,469.00 $448.00 $1,047.00 $406.00 $393.00 $1,413.00 $1,726.00 $916.00 $253.00 $1,149.00 $1,151.00 $1,194.00 $221.00 $179.00 $952.00 $130.00 $228.00 $251.00 $337.00 $305.00 $176.00 $86.00 --------


Part B, 273



10 10 10 0 0 90 90 90 90 90 90 0 10 0 0 0 10 YYY 90 90 YYY 10 10 0 10 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90

$52.00 $175.00 $109.00 $85.00 $87.00 $294.00 $274.00 $722.00 $248.00 $1,111.00 $1,680.00 $53.00 $110.00 -------$39.00 $78.00 $123.00 $522.00 $937.00 $1,434.00 BR $117.00 $155.00 $84.00 $145.00 $182.00 $699.00 $525.00 $829.00 $1,118.00 $1,176.00 $1,221.00 $1,616.00 $2,824.00 $126.00 $998.00 $1,621.00 $2,600.00 $1,195.00 $1,225.00 $1,264.00 $1,263.00 $1,526.00 $41.00 $651.00 $985.00 $1,166.00 $1,110.00 $1,207.00 $1,381.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$264.00 $306.00 $328.00 $141.00 $197.00 $648.00 $580.00 $1,255.00 $561.00 $1,518.00 $2,427.00 $140.00 $146.00 $18.00 $70.00 $156.00 $310.00 $1,046.00 $1,568.00 $2,230.00 -------$271.00 $215.00 $180.00 $287.00 $232.00 $994.00 $784.00 $1,063.00 $1,410.00 $1,733.00 $1,771.00 $2,396.00 $3,915.00 $294.00 $1,499.00 $2,265.00 $3,550.00 $1,517.00 $1,576.00 $1,838.00 $1,612.00 $2,256.00 $552.00 $989.00 $1,276.00 $1,556.00 $1,510.00 $1,783.00 $1,993.00

$280.00 $325.00 $350.00 $150.00 $210.00 $691.00 $616.00 $1,334.00 $598.00 $1,611.00 $2,570.00 $148.00 $155.00 $19.00 $74.00 $167.00 $330.00 $1,111.00 $1,668.00 $2,371.00 -------$289.00 $228.00 $192.00 $306.00 $246.00 $1,055.00 $833.00 $1,127.00 $1,495.00 $1,840.00 $1,880.00 $2,542.00 $4,154.00 $314.00 $1,592.00 $2,402.00 $3,756.00 $1,608.00 $1,671.00 $1,953.00 $1,709.00 $2,394.00 $586.00 $1,053.00 $1,354.00 $1,651.00 $1,603.00 $1,895.00 $2,116.00

$288.00 $338.00 $359.00 $154.00 $216.00 $714.00 $640.00 $1,382.00 $614.00 $1,693.00 $2,706.00 $153.00 $162.00 $19.00 $77.00 $172.00 $339.00 $1,149.00 $1,734.00 $2,478.00 -------$297.00 $239.00 $197.00 $315.00 $258.00 $1,101.00 $866.00 $1,181.00 $1,569.00 $1,917.00 $1,959.00 $2,661.00 $4,389.00 $322.00 $1,656.00 $2,516.00 $3,959.00 $1,685.00 $1,751.00 $2,041.00 $1,791.00 $2,502.00 $612.00 $1,089.00 $1,413.00 $1,726.00 $1,676.00 $1,979.00 $2,205.00

$171.00 $228.00 $204.00 $71.00 $92.00 $466.00 $580.00 $1,255.00 $359.00 $1,518.00 $2,427.00 $69.00 $146.00 $18.00 $48.00 $76.00 $197.00 $693.00 $1,568.00 $2,230.00 -------$174.00 $215.00 $90.00 $192.00 $232.00 $994.00 $784.00 $1,063.00 $1,410.00 $1,733.00 $1,771.00 $2,396.00 $3,915.00 $182.00 $1,499.00 $2,265.00 $3,550.00 $1,517.00 $1,576.00 $1,838.00 $1,612.00 $2,256.00 $425.00 $708.00 $1,276.00 $1,556.00 $1,510.00 $1,783.00 $1,993.00

$181.00 $241.00 $217.00 $75.00 $98.00 $496.00 $616.00 $1,334.00 $382.00 $1,611.00 $2,570.00 $72.00 $155.00 $19.00 $50.00 $80.00 $209.00 $733.00 $1,668.00 $2,371.00 -------$184.00 $228.00 $96.00 $203.00 $246.00 $1,055.00 $833.00 $1,127.00 $1,495.00 $1,840.00 $1,880.00 $2,542.00 $4,154.00 $194.00 $1,592.00 $2,402.00 $3,756.00 $1,608.00 $1,671.00 $1,953.00 $1,709.00 $2,394.00 $449.00 $751.00 $1,354.00 $1,651.00 $1,603.00 $1,895.00 $2,116.00

$188.00 $254.00 $226.00 $80.00 $103.00 $518.00 $640.00 $1,382.00 $397.00 $1,693.00 $2,706.00 $76.00 $162.00 $19.00 $53.00 $85.00 $217.00 $770.00 $1,734.00 $2,478.00 -------$193.00 $239.00 $101.00 $213.00 $258.00 $1,101.00 $866.00 $1,181.00 $1,569.00 $1,917.00 $1,959.00 $2,661.00 $4,389.00 $201.00 $1,656.00 $2,516.00 $3,959.00 $1,685.00 $1,751.00 $2,041.00 $1,791.00 $2,502.00 $475.00 $786.00 $1,413.00 $1,726.00 $1,676.00 $1,979.00 $2,205.00


Part B, 274


Surgery CPT Code FUD 2003 MRA 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69710 69711 69714 69715 69717 69718 69720 69725 69740 69745 69799 69801 69805 69806 69820 69840 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 69990 G0127 G0168 G0247 G0276 G0289 G0341 G0342

90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90 90 YYY 90 90 90 90 YYY ZZZ 0 0 ZZZ 0 ZZZ 0 90

$1,370.00 $1,154.00 $1,519.00 $1,389.00 $1,529.00 $1,479.00 $1,620.00 $879.00 $1,072.00 $1,412.00 $1,386.00 $887.00 $887.00 $988.00 $828.00 $702.00 BR $878.00 $961.00 $1,217.00 $996.00 $1,232.00 $1,307.00 $1,922.00 $1,274.00 $1,447.00 BR $785.00 $1,187.00 $1,123.00 $876.00 $869.00 $1,013.00 $1,228.00 $1,754.00 $1,498.00 BR $2,017.00 $2,185.00 $2,116.00 $2,306.00 BR $262.00 --------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,982.00 $1,507.00 $1,936.00 $1,775.00 $2,134.00 $2,099.00 $2,232.00 $1,165.00 $1,345.00 $1,755.00 $1,685.00 $1,170.00 $1,170.00 $1,373.00 $1,200.00 $992.00 -------$1,250.00 $1,567.00 $1,937.00 $1,646.00 $1,956.00 $1,770.00 $2,744.00 $1,699.00 $2,060.00 -------$280.00 $1,534.00 $1,373.00 $1,240.00 $1,299.00 $1,328.00 $1,479.00 $2,247.00 $1,786.00 -------$2,609.00 $2,913.00 $2,803.00 $3,137.00 -------$342.00 $32.00 $142.00 $100.00 $585.00 $130.00 $3,170.00 $1,024.00

$2,104.00 $1,599.00 $2,053.00 $1,882.00 $2,265.00 $2,228.00 $2,368.00 $1,236.00 $1,426.00 $1,861.00 $1,786.00 $1,241.00 $1,241.00 $1,456.00 $1,273.00 $1,052.00 -------$1,326.00 $1,661.00 $2,050.00 $1,744.00 $2,071.00 $1,885.00 $2,904.00 $1,799.00 $2,220.00 -------$298.00 $1,625.00 $1,455.00 $1,315.00 $1,375.00 $1,408.00 $1,567.00 $2,377.00 $1,891.00 -------$2,759.00 $3,084.00 $2,962.00 $3,321.00 -------$375.00 $34.00 $151.00 $106.00 $620.00 $138.00 $3,385.00 $1,079.00

$2,193.00 $1,673.00 $2,151.00 $1,973.00 $2,365.00 $2,327.00 $2,475.00 $1,292.00 $1,496.00 $1,954.00 $1,878.00 $1,298.00 $1,299.00 $1,526.00 $1,329.00 $1,100.00 -------$1,386.00 $1,746.00 $2,159.00 $1,833.00 $2,181.00 $1,988.00 $3,063.00 $1,893.00 $2,405.00 -------$310.00 $1,709.00 $1,528.00 $1,376.00 $1,427.00 $1,474.00 $1,647.00 $2,508.00 $1,993.00 -------$2,917.00 $3,256.00 $3,123.00 $3,512.00 -------$428.00 $34.00 $154.00 $108.00 $667.00 $150.00 $3,417.00 $1,144.00

$1,982.00 $1,507.00 $1,936.00 $1,775.00 $2,134.00 $2,099.00 $2,232.00 $1,165.00 $1,345.00 $1,755.00 $1,685.00 $1,170.00 $1,170.00 $1,373.00 $1,200.00 $992.00 -------$1,250.00 $1,567.00 $1,937.00 $1,646.00 $1,956.00 $1,770.00 $2,744.00 $1,699.00 $2,060.00 -------$185.00 $1,534.00 $1,373.00 $1,240.00 $1,299.00 $1,328.00 $1,479.00 $2,247.00 $1,786.00 -------$2,609.00 $2,913.00 $2,803.00 $3,137.00 -------$342.00 $11.00 $40.00 $33.00 $585.00 $130.00 $547.00 $1,024.00

$2,104.00 $1,599.00 $2,053.00 $1,882.00 $2,265.00 $2,228.00 $2,368.00 $1,236.00 $1,426.00 $1,861.00 $1,786.00 $1,241.00 $1,241.00 $1,456.00 $1,273.00 $1,052.00 -------$1,326.00 $1,661.00 $2,050.00 $1,744.00 $2,071.00 $1,885.00 $2,904.00 $1,799.00 $2,220.00 -------$195.00 $1,625.00 $1,455.00 $1,315.00 $1,375.00 $1,408.00 $1,567.00 $2,377.00 $1,891.00 -------$2,759.00 $3,084.00 $2,962.00 $3,321.00 -------$375.00 $11.00 $43.00 $34.00 $620.00 $138.00 $570.00 $1,079.00

$2,193.00 $1,673.00 $2,151.00 $1,973.00 $2,365.00 $2,327.00 $2,475.00 $1,292.00 $1,496.00 $1,954.00 $1,878.00 $1,298.00 $1,299.00 $1,526.00 $1,329.00 $1,100.00 -------$1,386.00 $1,746.00 $2,159.00 $1,833.00 $2,181.00 $1,988.00 $3,063.00 $1,893.00 $2,405.00 -------$207.00 $1,709.00 $1,528.00 $1,376.00 $1,427.00 $1,474.00 $1,647.00 $2,508.00 $1,993.00 -------$2,917.00 $3,256.00 $3,123.00 $3,512.00 -------$428.00 $12.00 $45.00 $36.00 $667.00 $150.00 $594.00 $1,144.00


Part B, 275


Surgery CPT Code FUD 2003 MRA G0343 G0364 G0412 G0413 G0414 G0415 G0429

90 ZZZ 90 90 90 90 0

--------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$1,849.00 $17.00 $1,051.00 $1,570.00 $1,412.00 $2,019.00 $139.00

$1,985.00 $18.00 $1,121.00 $1,676.00 $1,494.00 $2,154.00 $148.00

$2,175.00 $19.00 $1,203.00 $1,802.00 $1,581.00 $2,320.00 $154.00

$1,849.00 $13.00 $1,051.00 $1,570.00 $1,412.00 $2,019.00 $103.00

$1,985.00 $13.00 $1,121.00 $1,676.00 $1,494.00 $2,154.00 $109.00

$2,175.00 $13.00 $1,203.00 $1,802.00 $1,581.00 $2,320.00 $115.00


Part B, 276


PART C SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES

2016 Edition

Page 277



Radiology CPT Code

2003 MRA

70010 70010-26 70010-TC 70015 70015-26 70015-TC 70030 70030-26 70030-TC 70100 70100-26 70100-TC 70110 70110-26 70110-TC 70120 70120-26 70120-TC 70130 70130-26 70130-TC 70134 70134-26 70134-TC 70140 70140-26 70140-TC 70150 70150-26 70150-TC 70160 70160-26 70160-TC 70170 70170-26 70170-TC 70190 70190-26 70190-TC 70200 70200-26 70200-TC 70210 70210-26 70210-TC 70220 70220-26 70220-TC 70240 70240-26

$70.00 NC NC $58.00 NC NC $24.00 $10.00 $15.00 $29.00 $9.00 $19.00 $36.00 $12.00 $22.00 $32.00 $9.00 $22.00 $46.00 $17.00 $29.00 $45.00 $17.00 $28.00 $33.00 $9.00 $22.00 $42.00 $12.00 $29.00 $29.00 $8.00 $19.00 $52.00 NC NC $34.00 $10.00 $22.00 $43.00 $14.00 $29.00 $32.00 $8.00 $22.00 $42.00 $12.00 $29.00 $26.00 $9.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$69.00 BR BR $167.00 $71.00 $97.00 $30.00 $9.00 $21.00 $35.00 $10.00 $25.00 $41.00 $14.00 $27.00 $36.00 $10.00 $26.00 $59.00 $19.00 $39.00 $55.00 $20.00 $36.00 $32.00 $12.00 $20.00 $45.00 $15.00 $30.00 $35.00 $10.00 $25.00 $388.00 $17.00 $371.00 $38.00 $13.00 $26.00 $45.00 $16.00 $30.00 $32.00 $10.00 $22.00 $40.00 $14.00 $26.00 $32.00 $11.00

$72.00 BR BR $178.00 $74.00 $104.00 $32.00 $10.00 $22.00 $38.00 $11.00 $27.00 $43.00 $15.00 $29.00 $39.00 $11.00 $28.00 $62.00 $20.00 $42.00 $59.00 $20.00 $38.00 $34.00 $12.00 $22.00 $47.00 $15.00 $32.00 $37.00 $10.00 $27.00 $415.00 $18.00 $398.00 $41.00 $13.00 $28.00 $48.00 $16.00 $32.00 $34.00 $10.00 $24.00 $43.00 $15.00 $28.00 $34.00 $11.00

$75.00 BR BR $182.00 $78.00 $104.00 $33.00 $10.00 $23.00 $38.00 $11.00 $27.00 $44.00 $15.00 $29.00 $40.00 $11.00 $29.00 $64.00 $21.00 $43.00 $59.00 $20.00 $39.00 $35.00 $13.00 $22.00 $48.00 $16.00 $32.00 $38.00 $11.00 $27.00 $418.00 $18.00 $399.00 $42.00 $13.00 $28.00 $49.00 $16.00 $32.00 $35.00 $11.00 $24.00 $44.00 $15.00 $29.00 $35.00 $12.00

$69.00 BR BR $167.00 $71.00 $97.00 $30.00 $9.00 $21.00 $35.00 $10.00 $25.00 $41.00 $14.00 $27.00 $36.00 $10.00 $26.00 $59.00 $19.00 $39.00 $55.00 $20.00 $36.00 $32.00 $12.00 $20.00 $45.00 $15.00 $30.00 $35.00 $10.00 $25.00 $388.00 $17.00 $371.00 $38.00 $13.00 $26.00 $45.00 $16.00 $30.00 $32.00 $10.00 $22.00 $40.00 $14.00 $26.00 $32.00 $11.00


Locality 01/02 Locality 03

Locality 04

(Facility MRA) (Facility MRA)

$72.00 BR BR $178.00 $74.00 $104.00 $32.00 $10.00 $22.00 $38.00 $11.00 $27.00 $43.00 $15.00 $29.00 $39.00 $11.00 $28.00 $62.00 $20.00 $42.00 $59.00 $20.00 $38.00 $34.00 $12.00 $22.00 $47.00 $15.00 $32.00 $37.00 $10.00 $27.00 $415.00 $18.00 $398.00 $41.00 $13.00 $28.00 $48.00 $16.00 $32.00 $34.00 $10.00 $24.00 $43.00 $15.00 $28.00 $34.00 $11.00

$75.00 BR BR $182.00 $78.00 $104.00 $33.00 $10.00 $23.00 $38.00 $11.00 $27.00 $44.00 $15.00 $29.00 $40.00 $11.00 $29.00 $64.00 $21.00 $43.00 $59.00 $20.00 $39.00 $35.00 $13.00 $22.00 $48.00 $16.00 $32.00 $38.00 $11.00 $27.00 $418.00 $18.00 $399.00 $42.00 $13.00 $28.00 $49.00 $16.00 $32.00 $35.00 $11.00 $24.00 $44.00 $15.00 $29.00 $35.00 $12.00

Part C, 278


Radiology CPT Code

2003 MRA

70240-TC 70250 70250-26 70250-TC 70260 70260-26 70260-TC 70300 70300-26 70300-TC 70310 70310-26 70310-TC 70320 70320-26 70320-TC 70328 70328-26 70328-TC 70330 70330-26 70330-TC 70332 70332-26 70332-TC 70336 70336-26 70336-TC 70350 70350-26 70350-TC 70355 70355-26 70355-TC 70360 70360-26 70360-TC 70370 70370-26 70370-TC 70371 70371-26 70371-TC 70380 70380-26 70380-TC 70390 70390-26 70390-TC 70450

$15.00 $35.00 $12.00 $22.00 $50.00 $17.00 $33.00 $15.00 $5.00 $10.00 $24.00 $8.00 $15.00 $40.00 $11.00 $29.00 $28.00 $10.00 $18.00 $43.00 $12.00 $31.00 $107.00 NC NC $497.00 $72.00 $419.00 $24.00 $10.00 $14.00 $32.00 $10.00 $21.00 $24.00 $8.00 $15.00 $65.00 $16.00 $48.00 $122.00 $43.00 $79.00 $34.00 $8.00 $24.00 $87.00 NC NC $221.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$21.00 $39.00 $14.00 $25.00 $49.00 $20.00 $30.00 $16.00 $7.00 $10.00 $39.00 $9.00 $30.00 $56.00 $13.00 $43.00 $33.00 $10.00 $23.00 $51.00 $14.00 $36.00 $88.00 $35.00 $53.00 $345.00 $83.00 $262.00 $22.00 $12.00 $10.00 $23.00 $13.00 $10.00 $30.00 $9.00 $21.00 $82.00 $18.00 $64.00 $99.00 $48.00 $51.00 $39.00 $10.00 $28.00 $101.00 $21.00 $80.00 $126.00

$23.00 $41.00 $15.00 $27.00 $52.00 $20.00 $32.00 $17.00 $7.00 $10.00 $42.00 $9.00 $33.00 $60.00 $14.00 $46.00 $35.00 $11.00 $25.00 $54.00 $15.00 $39.00 $93.00 $37.00 $57.00 $367.00 $86.00 $281.00 $23.00 $12.00 $11.00 $24.00 $13.00 $11.00 $32.00 $10.00 $23.00 $88.00 $19.00 $69.00 $105.00 $50.00 $55.00 $41.00 $11.00 $31.00 $107.00 $22.00 $85.00 $133.00

$23.00 $42.00 $15.00 $27.00 $53.00 $21.00 $32.00 $18.00 $7.00 $11.00 $43.00 $10.00 $33.00 $61.00 $14.00 $47.00 $36.00 $11.00 $25.00 $55.00 $15.00 $40.00 $95.00 $38.00 $57.00 $371.00 $88.00 $283.00 $24.00 $13.00 $12.00 $25.00 $14.00 $11.00 $33.00 $10.00 $23.00 $89.00 $19.00 $69.00 $107.00 $51.00 $55.00 $42.00 $11.00 $31.00 $109.00 $23.00 $86.00 $135.00

$21.00 $39.00 $14.00 $25.00 $49.00 $20.00 $30.00 $16.00 $7.00 $10.00 $39.00 $9.00 $30.00 $56.00 $13.00 $43.00 $33.00 $10.00 $23.00 $51.00 $14.00 $36.00 $88.00 $35.00 $53.00 $345.00 $83.00 $262.00 $22.00 $12.00 $10.00 $23.00 $13.00 $10.00 $30.00 $9.00 $21.00 $82.00 $18.00 $64.00 $99.00 $48.00 $51.00 $39.00 $10.00 $28.00 $101.00 $21.00 $80.00 $126.00



Locality 04


$23.00 $41.00 $15.00 $27.00 $52.00 $20.00 $32.00 $17.00 $7.00 $10.00 $42.00 $9.00 $33.00 $60.00 $14.00 $46.00 $35.00 $11.00 $25.00 $54.00 $15.00 $39.00 $93.00 $37.00 $57.00 $367.00 $86.00 $281.00 $23.00 $12.00 $11.00 $24.00 $13.00 $11.00 $32.00 $10.00 $23.00 $88.00 $19.00 $69.00 $105.00 $50.00 $55.00 $41.00 $11.00 $31.00 $107.00 $22.00 $85.00 $133.00

$23.00 $42.00 $15.00 $27.00 $53.00 $21.00 $32.00 $18.00 $7.00 $11.00 $43.00 $10.00 $33.00 $61.00 $14.00 $47.00 $36.00 $11.00 $25.00 $55.00 $15.00 $40.00 $95.00 $38.00 $57.00 $371.00 $88.00 $283.00 $24.00 $13.00 $12.00 $25.00 $14.00 $11.00 $33.00 $10.00 $23.00 $89.00 $19.00 $69.00 $107.00 $51.00 $55.00 $42.00 $11.00 $31.00 $109.00 $23.00 $86.00 $135.00

Part C, 279


Radiology CPT Code

2003 MRA

70450-26 70450-TC 70460 70460-26 70460-TC 70470 70470-26 70470-TC 70480 70480-26 70480-TC 70481 70481-26 70481-TC 70482 70482-26 70482-TC 70486 70486-26 70486-TC 70487 70487-26 70487-TC 70488 70488-26 70488-TC 70490 70490-26 70490-TC 70491 70491-26 70491-TC 70492 70492-26 70492-TC 70496 70496-26 70496-TC 70498 70498-26 70498-TC 70540 70540-26 70540-TC 70542 70542-26 70542-TC 70543 70543-26 70543-TC

$43.00 $176.00 $271.00 $58.00 $211.00 $332.00 $65.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $236.00 $58.00 $176.00 $279.00 $66.00 $211.00 $339.00 $72.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $366.00 $92.00 $270.00 $366.00 $92.00 $270.00 $482.00 $70.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$48.00 $78.00 $175.00 $63.00 $111.00 $207.00 $72.00 $135.00 $191.00 $72.00 $119.00 $297.00 $78.00 $219.00 $324.00 $81.00 $243.00 $151.00 $48.00 $103.00 $182.00 $63.00 $118.00 $221.00 $71.00 $150.00 $191.00 $72.00 $119.00 $254.00 $78.00 $176.00 $299.00 $82.00 $218.00 $317.00 $98.00 $219.00 $316.00 $98.00 $218.00 $364.00 $76.00 $288.00 $431.00 $91.00 $340.00 $528.00 $121.00 $407.00

$50.00 $83.00 $185.00 $66.00 $120.00 $220.00 $74.00 $145.00 $202.00 $75.00 $128.00 $316.00 $80.00 $236.00 $345.00 $84.00 $261.00 $160.00 $50.00 $111.00 $193.00 $66.00 $127.00 $235.00 $74.00 $161.00 $202.00 $75.00 $128.00 $270.00 $81.00 $189.00 $318.00 $84.00 $234.00 $337.00 $102.00 $235.00 $336.00 $102.00 $234.00 $388.00 $78.00 $310.00 $459.00 $94.00 $365.00 $562.00 $125.00 $437.00

$51.00 $84.00 $188.00 $67.00 $120.00 $223.00 $76.00 $146.00 $205.00 $77.00 $128.00 $319.00 $83.00 $237.00 $349.00 $87.00 $262.00 $163.00 $51.00 $111.00 $195.00 $67.00 $128.00 $238.00 $76.00 $162.00 $205.00 $77.00 $128.00 $273.00 $83.00 $190.00 $321.00 $87.00 $235.00 $341.00 $105.00 $237.00 $340.00 $105.00 $235.00 $392.00 $81.00 $311.00 $464.00 $97.00 $367.00 $568.00 $129.00 $439.00

$48.00 $78.00 $175.00 $63.00 $111.00 $207.00 $72.00 $135.00 $191.00 $72.00 $119.00 $297.00 $78.00 $219.00 $324.00 $81.00 $243.00 $151.00 $48.00 $103.00 $182.00 $63.00 $118.00 $221.00 $71.00 $150.00 $191.00 $72.00 $119.00 $254.00 $78.00 $176.00 $299.00 $82.00 $218.00 $317.00 $98.00 $219.00 $316.00 $98.00 $218.00 $364.00 $76.00 $288.00 $431.00 $91.00 $340.00 $528.00 $121.00 $407.00



Locality 04


$50.00 $83.00 $185.00 $66.00 $120.00 $220.00 $74.00 $145.00 $202.00 $75.00 $128.00 $316.00 $80.00 $236.00 $345.00 $84.00 $261.00 $160.00 $50.00 $111.00 $193.00 $66.00 $127.00 $235.00 $74.00 $161.00 $202.00 $75.00 $128.00 $270.00 $81.00 $189.00 $318.00 $84.00 $234.00 $337.00 $102.00 $235.00 $336.00 $102.00 $234.00 $388.00 $78.00 $310.00 $459.00 $94.00 $365.00 $562.00 $125.00 $437.00

$51.00 $84.00 $188.00 $67.00 $120.00 $223.00 $76.00 $146.00 $205.00 $77.00 $128.00 $319.00 $83.00 $237.00 $349.00 $87.00 $262.00 $163.00 $51.00 $111.00 $195.00 $67.00 $128.00 $238.00 $76.00 $162.00 $205.00 $77.00 $128.00 $273.00 $83.00 $190.00 $321.00 $87.00 $235.00 $341.00 $105.00 $237.00 $340.00 $105.00 $235.00 $392.00 $81.00 $311.00 $464.00 $97.00 $367.00 $568.00 $129.00 $439.00

Part C, 280


Radiology CPT Code

2003 MRA


$481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $497.00 $76.00 $419.00 $596.00 $91.00 $502.00 $1,055.00 $120.00 $931.00 ------------------------------------------------------------------------------------------------------------------------$27.00 $9.00 $17.00 $30.00 $10.00 $19.00 $35.00 $11.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$356.00 $68.00 $288.00 $415.00 $68.00 $347.00 $580.00 $101.00 $479.00 $356.00 $68.00 $288.00 $442.00 $68.00 $374.00 $580.00 $101.00 $479.00 $249.00 $83.00 $165.00 $344.00 $100.00 $244.00 $407.00 $129.00 $278.00 $485.00 $120.00 $365.00 BR $142.00 BR $452.00 $164.00 $288.00 $659.00 $181.00 $478.00 $3,046.00 $183.00 $2,863.00 $24.00 $10.00 $14.00 $30.00 $12.00 $18.00 $30.00 $12.00

$380.00 $70.00 $310.00 $442.00 $70.00 $373.00 $619.00 $105.00 $514.00 $380.00 $70.00 $310.00 $472.00 $70.00 $402.00 $619.00 $105.00 $514.00 $264.00 $86.00 $178.00 $366.00 $104.00 $262.00 $432.00 $133.00 $299.00 $516.00 $124.00 $392.00 BR $147.00 BR $479.00 $170.00 $309.00 $700.00 $187.00 $513.00 $3,262.00 $189.00 $3,072.00 $26.00 $11.00 $15.00 $32.00 $13.00 $19.00 $32.00 $13.00

$384.00 $72.00 $311.00 $446.00 $72.00 $374.00 $624.00 $108.00 $516.00 $384.00 $72.00 $311.00 $476.00 $72.00 $404.00 $624.00 $108.00 $516.00 $267.00 $89.00 $178.00 $370.00 $107.00 $264.00 $438.00 $138.00 $300.00 $522.00 $128.00 $394.00 BR $151.00 BR $486.00 $175.00 $311.00 $708.00 $193.00 $515.00 $3,277.00 $196.00 $3,082.00 $27.00 $11.00 $16.00 $33.00 $13.00 $20.00 $33.00 $13.00

$356.00 $68.00 $288.00 $415.00 $68.00 $347.00 $580.00 $101.00 $479.00 $356.00 $68.00 $288.00 $442.00 $68.00 $374.00 $580.00 $101.00 $479.00 $249.00 $83.00 $165.00 $344.00 $100.00 $244.00 $407.00 $129.00 $278.00 $485.00 $120.00 $365.00 BR $142.00 BR $452.00 $164.00 $288.00 $659.00 $181.00 $478.00 $3,046.00 $183.00 $2,863.00 $24.00 $10.00 $14.00 $30.00 $12.00 $18.00 $30.00 $12.00



Locality 04


$380.00 $70.00 $310.00 $442.00 $70.00 $373.00 $619.00 $105.00 $514.00 $380.00 $70.00 $310.00 $472.00 $70.00 $402.00 $619.00 $105.00 $514.00 $264.00 $86.00 $178.00 $366.00 $104.00 $262.00 $432.00 $133.00 $299.00 $516.00 $124.00 $392.00 BR $147.00 BR $479.00 $170.00 $309.00 $700.00 $187.00 $513.00 $3,262.00 $189.00 $3,072.00 $26.00 $11.00 $15.00 $32.00 $13.00 $19.00 $32.00 $13.00

$384.00 $72.00 $311.00 $446.00 $72.00 $374.00 $624.00 $108.00 $516.00 $384.00 $72.00 $311.00 $476.00 $72.00 $404.00 $624.00 $108.00 $516.00 $267.00 $89.00 $178.00 $370.00 $107.00 $264.00 $438.00 $138.00 $300.00 $522.00 $128.00 $394.00 BR $151.00 BR $486.00 $175.00 $311.00 $708.00 $193.00 $515.00 $3,277.00 $196.00 $3,082.00 $27.00 $11.00 $16.00 $33.00 $13.00 $20.00 $33.00 $13.00

Part C, 281


Radiology CPT Code

2003 MRA


$22.00 $41.00 $13.00 $28.00 $44.00 $16.00 $28.00 $49.00 $19.00 $29.00 $45.00 $16.00 $29.00 $79.00 $23.00 $54.00 $56.00 $19.00 $38.00 $33.00 $11.00 $21.00 $38.00 $13.00 $24.00 $43.00 $13.00 $29.00 $49.00 $16.00 $33.00 $35.00 $10.00 $24.00 $38.00 $11.00 $26.00 $282.00 $59.00 $220.00 $328.00 $63.00 $264.00 $402.00 $70.00 $330.00 $431.00 $100.00 $328.00 $490.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$18.00 $37.00 $15.00 $21.00 $45.00 $18.00 $27.00 $68.00 $21.00 $47.00 $45.00 $18.00 $27.00 $90.00 $27.00 $63.00 $35.00 $10.00 $25.00 $35.00 $13.00 $23.00 $39.00 $15.00 $24.00 $40.00 $15.00 $25.00 $52.00 $19.00 $33.00 $32.00 $11.00 $21.00 $39.00 $13.00 $26.00 $177.00 $58.00 $119.00 $247.00 $70.00 $177.00 $296.00 $78.00 $218.00 $323.00 $102.00 $221.00 $370.00

$19.00 $39.00 $16.00 $23.00 $48.00 $19.00 $29.00 $73.00 $22.00 $51.00 $48.00 $18.00 $29.00 $96.00 $28.00 $68.00 $38.00 $11.00 $27.00 $38.00 $13.00 $25.00 $42.00 $16.00 $26.00 $43.00 $16.00 $27.00 $55.00 $19.00 $36.00 $34.00 $12.00 $22.00 $41.00 $13.00 $28.00 $187.00 $60.00 $128.00 $262.00 $73.00 $190.00 $315.00 $80.00 $234.00 $343.00 $106.00 $237.00 $394.00

$20.00 $39.00 $16.00 $23.00 $48.00 $19.00 $29.00 $74.00 $23.00 $51.00 $49.00 $19.00 $30.00 $97.00 $29.00 $69.00 $38.00 $11.00 $27.00 $38.00 $13.00 $25.00 $43.00 $17.00 $26.00 $44.00 $16.00 $27.00 $56.00 $20.00 $36.00 $35.00 $12.00 $23.00 $42.00 $13.00 $29.00 $190.00 $62.00 $128.00 $265.00 $75.00 $191.00 $318.00 $83.00 $235.00 $347.00 $109.00 $239.00 $398.00

$18.00 $37.00 $15.00 $21.00 $45.00 $18.00 $27.00 $68.00 $21.00 $47.00 $45.00 $18.00 $27.00 $90.00 $27.00 $63.00 $35.00 $10.00 $25.00 $35.00 $13.00 $23.00 $39.00 $15.00 $24.00 $40.00 $15.00 $25.00 $52.00 $19.00 $33.00 $32.00 $11.00 $21.00 $39.00 $13.00 $26.00 $177.00 $58.00 $119.00 $247.00 $70.00 $177.00 $296.00 $78.00 $218.00 $323.00 $102.00 $221.00 $370.00



Locality 04


$19.00 $39.00 $16.00 $23.00 $48.00 $19.00 $29.00 $73.00 $22.00 $51.00 $48.00 $18.00 $29.00 $96.00 $28.00 $68.00 $38.00 $11.00 $27.00 $38.00 $13.00 $25.00 $42.00 $16.00 $26.00 $43.00 $16.00 $27.00 $55.00 $19.00 $36.00 $34.00 $12.00 $22.00 $41.00 $13.00 $28.00 $187.00 $60.00 $128.00 $262.00 $73.00 $190.00 $315.00 $80.00 $234.00 $343.00 $106.00 $237.00 $394.00

$20.00 $39.00 $16.00 $23.00 $48.00 $19.00 $29.00 $74.00 $23.00 $51.00 $49.00 $19.00 $30.00 $97.00 $29.00 $69.00 $38.00 $11.00 $27.00 $38.00 $13.00 $25.00 $43.00 $17.00 $26.00 $44.00 $16.00 $27.00 $56.00 $20.00 $36.00 $35.00 $12.00 $23.00 $42.00 $13.00 $29.00 $190.00 $62.00 $128.00 $265.00 $75.00 $191.00 $318.00 $83.00 $235.00 $347.00 $109.00 $239.00 $398.00

Part C, 282


Radiology CPT Code

2003 MRA


$75.00 $415.00 $587.00 $88.00 $496.00 $1,029.00 $114.00 $911.00 $514.00 $92.00 $419.00 $22.00 $7.00 $15.00 $34.00 $11.00 $22.00 $49.00 $16.00 $33.00 $61.00 $18.00 $42.00 $36.00 $11.00 $24.00 $39.00 $11.00 $28.00 $45.00 $11.00 $34.00 $36.00 $11.00 $24.00 ------------------------------------------------------------------------------------------------$36.00 $11.00 $24.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$82.00 $288.00 $491.00 $97.00 $394.00 $606.00 $128.00 $479.00 $427.00 $101.00 $326.00 $24.00 $9.00 $15.00 $36.00 $13.00 $23.00 $49.00 $18.00 $31.00 $61.00 $21.00 $40.00 $37.00 $13.00 $24.00 $37.00 $12.00 $25.00 $42.00 $12.00 $30.00 $33.00 $12.00 $21.00 $42.00 $15.00 $27.00 $67.00 $18.00 $49.00 $73.00 $20.00 $53.00 $87.00 $23.00 $64.00 $38.00 $13.00 $25.00

$85.00 $310.00 $524.00 $100.00 $423.00 $646.00 $132.00 $514.00 $454.00 $104.00 $350.00 $26.00 $9.00 $16.00 $38.00 $13.00 $25.00 $52.00 $18.00 $33.00 $64.00 $21.00 $43.00 $39.00 $13.00 $26.00 $40.00 $13.00 $27.00 $45.00 $13.00 $32.00 $35.00 $13.00 $23.00 $45.00 $16.00 $29.00 $71.00 $19.00 $53.00 $77.00 $20.00 $57.00 $92.00 $24.00 $69.00 $40.00 $13.00 $27.00

$87.00 $311.00 $529.00 $104.00 $425.00 $652.00 $136.00 $516.00 $458.00 $107.00 $352.00 $26.00 $9.00 $17.00 $39.00 $13.00 $25.00 $53.00 $19.00 $34.00 $66.00 $22.00 $44.00 $40.00 $13.00 $26.00 $40.00 $13.00 $27.00 $46.00 $13.00 $33.00 $36.00 $13.00 $23.00 $46.00 $16.00 $29.00 $73.00 $19.00 $53.00 $79.00 $21.00 $58.00 $94.00 $24.00 $69.00 $41.00 $13.00 $27.00

$82.00 $288.00 $491.00 $97.00 $394.00 $606.00 $128.00 $479.00 $427.00 $101.00 $326.00 $24.00 $9.00 $15.00 $36.00 $13.00 $23.00 $49.00 $18.00 $31.00 $61.00 $21.00 $40.00 $37.00 $13.00 $24.00 $37.00 $12.00 $25.00 $42.00 $12.00 $30.00 $33.00 $12.00 $21.00 $42.00 $15.00 $27.00 $67.00 $18.00 $49.00 $73.00 $20.00 $53.00 $87.00 $23.00 $64.00 $38.00 $13.00 $25.00



Locality 04


$85.00 $310.00 $524.00 $100.00 $423.00 $646.00 $132.00 $514.00 $454.00 $104.00 $350.00 $26.00 $9.00 $16.00 $38.00 $13.00 $25.00 $52.00 $18.00 $33.00 $64.00 $21.00 $43.00 $39.00 $13.00 $26.00 $40.00 $13.00 $27.00 $45.00 $13.00 $32.00 $35.00 $13.00 $23.00 $45.00 $16.00 $29.00 $71.00 $19.00 $53.00 $77.00 $20.00 $57.00 $92.00 $24.00 $69.00 $40.00 $13.00 $27.00

$87.00 $311.00 $529.00 $104.00 $425.00 $652.00 $136.00 $516.00 $458.00 $107.00 $352.00 $26.00 $9.00 $17.00 $39.00 $13.00 $25.00 $53.00 $19.00 $34.00 $66.00 $22.00 $44.00 $40.00 $13.00 $26.00 $40.00 $13.00 $27.00 $46.00 $13.00 $33.00 $36.00 $13.00 $23.00 $46.00 $16.00 $29.00 $73.00 $19.00 $53.00 $79.00 $21.00 $58.00 $94.00 $24.00 $69.00 $41.00 $13.00 $27.00

Part C, 283


Radiology CPT Code

2003 MRA


$50.00 $16.00 $34.00 $64.00 $18.00 $44.00 $45.00 $11.00 $33.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $391.00 $65.00 $323.00 $503.00 $82.00 $419.00 $604.00 $99.00 $502.00 $549.00 $82.00 $465.00 $603.00 $98.00 $502.00 $543.00 $76.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$53.00 $18.00 $35.00 $67.00 $19.00 $49.00 $43.00 $13.00 $31.00 $179.00 $60.00 $119.00 $247.00 $69.00 $178.00 $291.00 $71.00 $220.00 $175.00 $56.00 $119.00 $247.00 $69.00 $178.00 $293.00 $71.00 $222.00 $175.00 $56.00 $119.00 $246.00 $69.00 $177.00 $291.00 $72.00 $219.00 $242.00 $84.00 $158.00 $350.00 $101.00 $249.00 $242.00 $84.00 $158.00 $346.00 $100.00 $246.00 $241.00 $84.00

$56.00 $18.00 $38.00 $71.00 $19.00 $52.00 $46.00 $13.00 $33.00 $190.00 $62.00 $128.00 $262.00 $71.00 $191.00 $310.00 $74.00 $236.00 $186.00 $58.00 $128.00 $262.00 $71.00 $191.00 $312.00 $74.00 $238.00 $186.00 $58.00 $128.00 $262.00 $71.00 $191.00 $310.00 $74.00 $236.00 $257.00 $87.00 $170.00 $372.00 $105.00 $267.00 $257.00 $87.00 $170.00 $368.00 $104.00 $264.00 $255.00 $87.00

$57.00 $19.00 $38.00 $73.00 $20.00 $53.00 $47.00 $13.00 $34.00 $193.00 $64.00 $128.00 $265.00 $73.00 $192.00 $313.00 $76.00 $237.00 $189.00 $60.00 $128.00 $265.00 $73.00 $192.00 $315.00 $76.00 $239.00 $189.00 $60.00 $128.00 $265.00 $73.00 $191.00 $313.00 $77.00 $237.00 $260.00 $89.00 $171.00 $377.00 $108.00 $269.00 $260.00 $89.00 $171.00 $372.00 $107.00 $266.00 $259.00 $89.00

$53.00 $18.00 $35.00 $67.00 $19.00 $49.00 $43.00 $13.00 $31.00 $179.00 $60.00 $119.00 $247.00 $69.00 $178.00 $291.00 $71.00 $220.00 $175.00 $56.00 $119.00 $247.00 $69.00 $178.00 $293.00 $71.00 $222.00 $175.00 $56.00 $119.00 $246.00 $69.00 $177.00 $291.00 $72.00 $219.00 $242.00 $84.00 $158.00 $350.00 $101.00 $249.00 $242.00 $84.00 $158.00 $346.00 $100.00 $246.00 $241.00 $84.00



Locality 04


$56.00 $18.00 $38.00 $71.00 $19.00 $52.00 $46.00 $13.00 $33.00 $190.00 $62.00 $128.00 $262.00 $71.00 $191.00 $310.00 $74.00 $236.00 $186.00 $58.00 $128.00 $262.00 $71.00 $191.00 $312.00 $74.00 $238.00 $186.00 $58.00 $128.00 $262.00 $71.00 $191.00 $310.00 $74.00 $236.00 $257.00 $87.00 $170.00 $372.00 $105.00 $267.00 $257.00 $87.00 $170.00 $368.00 $104.00 $264.00 $255.00 $87.00

$57.00 $19.00 $38.00 $73.00 $20.00 $53.00 $47.00 $13.00 $34.00 $193.00 $64.00 $128.00 $265.00 $73.00 $192.00 $313.00 $76.00 $237.00 $189.00 $60.00 $128.00 $265.00 $73.00 $192.00 $315.00 $76.00 $239.00 $189.00 $60.00 $128.00 $265.00 $73.00 $191.00 $313.00 $77.00 $237.00 $260.00 $89.00 $171.00 $377.00 $108.00 $269.00 $260.00 $89.00 $171.00 $372.00 $107.00 $266.00 $259.00 $89.00

Part C, 284


Radiology CPT Code

2003 MRA


$465.00 $597.00 $92.00 $502.00 $1,066.00 $131.00 $931.00 $1,066.00 $131.00 $931.00 $1,056.00 $121.00 $931.00 $563.00 $94.00 $465.00 $29.00 $8.00 $19.00 $35.00 $10.00 $24.00 $413.00 $94.00 $315.00 $278.00 $56.00 $220.00 $317.00 $59.00 $256.00 $380.00 $62.00 $317.00 $491.00 $74.00 $415.00 $526.00 $84.00 $442.00 $1,037.00 $114.00 $919.00 $517.00 $95.00 $419.00 $29.00 $9.00 $19.00 $33.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$157.00 $346.00 $101.00 $245.00 $409.00 $129.00 $280.00 $410.00 $129.00 $281.00 $408.00 $129.00 $279.00 $448.00 $102.00 $346.00 $34.00 $10.00 $24.00 $41.00 $12.00 $29.00 $329.00 $102.00 $228.00 $158.00 $62.00 $97.00 $243.00 $66.00 $178.00 $280.00 $69.00 $211.00 $371.00 $82.00 $288.00 $442.00 $98.00 $344.00 $543.00 $128.00 $416.00 $431.00 $101.00 $330.00 $31.00 $10.00 $21.00 $35.00

$169.00 $368.00 $105.00 $263.00 $434.00 $133.00 $301.00 $435.00 $133.00 $302.00 $433.00 $133.00 $300.00 $477.00 $105.00 $371.00 $36.00 $10.00 $26.00 $44.00 $13.00 $31.00 $350.00 $105.00 $244.00 $167.00 $64.00 $104.00 $259.00 $68.00 $191.00 $298.00 $71.00 $227.00 $395.00 $85.00 $310.00 $471.00 $101.00 $369.00 $578.00 $132.00 $446.00 $458.00 $104.00 $354.00 $33.00 $10.00 $23.00 $38.00

$169.00 $373.00 $108.00 $264.00 $440.00 $138.00 $302.00 $441.00 $138.00 $303.00 $439.00 $138.00 $301.00 $481.00 $108.00 $373.00 $37.00 $11.00 $27.00 $44.00 $13.00 $31.00 $355.00 $109.00 $246.00 $170.00 $65.00 $104.00 $262.00 $70.00 $192.00 $301.00 $73.00 $228.00 $399.00 $88.00 $311.00 $475.00 $104.00 $371.00 $584.00 $136.00 $448.00 $463.00 $107.00 $356.00 $33.00 $11.00 $23.00 $38.00

$157.00 $346.00 $101.00 $245.00 $409.00 $129.00 $280.00 $410.00 $129.00 $281.00 $408.00 $129.00 $279.00 $448.00 $102.00 $346.00 $34.00 $10.00 $24.00 $41.00 $12.00 $29.00 $329.00 $102.00 $228.00 $158.00 $62.00 $97.00 $243.00 $66.00 $178.00 $280.00 $69.00 $211.00 $371.00 $82.00 $288.00 $442.00 $98.00 $344.00 $543.00 $128.00 $416.00 $431.00 $101.00 $330.00 $31.00 $10.00 $21.00 $35.00



Locality 04


$169.00 $368.00 $105.00 $263.00 $434.00 $133.00 $301.00 $435.00 $133.00 $302.00 $433.00 $133.00 $300.00 $477.00 $105.00 $371.00 $36.00 $10.00 $26.00 $44.00 $13.00 $31.00 $350.00 $105.00 $244.00 $167.00 $64.00 $104.00 $259.00 $68.00 $191.00 $298.00 $71.00 $227.00 $395.00 $85.00 $310.00 $471.00 $101.00 $369.00 $578.00 $132.00 $446.00 $458.00 $104.00 $354.00 $33.00 $10.00 $23.00 $38.00

$169.00 $373.00 $108.00 $264.00 $440.00 $138.00 $302.00 $441.00 $138.00 $303.00 $439.00 $138.00 $301.00 $481.00 $108.00 $373.00 $37.00 $11.00 $27.00 $44.00 $13.00 $31.00 $355.00 $109.00 $246.00 $170.00 $65.00 $104.00 $262.00 $70.00 $192.00 $301.00 $73.00 $228.00 $399.00 $88.00 $311.00 $475.00 $104.00 $371.00 $584.00 $136.00 $448.00 $463.00 $107.00 $356.00 $33.00 $11.00 $23.00 $38.00

Part C, 285


Radiology CPT Code

2003 MRA


$9.00 $22.00 $30.00 $8.00 $21.00 $132.00 NC NC $129.00 NC NC $132.00 NC NC $176.00 NC NC $112.00 NC NC $101.00 NC NC $107.00 NC NC $28.00 $8.00 $19.00 $29.00 $8.00 $19.00 $26.00 $7.00 $17.00 $31.00 $9.00 $21.00 $68.00 NC NC $35.00 $10.00 $24.00 $30.00 $8.00 $21.00 $27.00 $7.00 $19.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$11.00 $25.00 $30.00 $10.00 $21.00 $106.00 $51.00 $55.00 $106.00 $52.00 $54.00 $100.00 $47.00 $53.00 $139.00 $75.00 $63.00 $125.00 $44.00 $81.00 $124.00 $68.00 $56.00 $107.00 $49.00 $58.00 $30.00 $9.00 $20.00 $32.00 $10.00 $22.00 $25.00 $9.00 $16.00 $31.00 $11.00 $21.00 $108.00 $31.00 $77.00 $38.00 $12.00 $26.00 $31.00 $9.00 $22.00 $29.00 $9.00 $20.00

$11.00 $27.00 $32.00 $10.00 $22.00 $112.00 $53.00 $59.00 $112.00 $54.00 $58.00 $106.00 $49.00 $57.00 $146.00 $78.00 $68.00 $132.00 $46.00 $87.00 $131.00 $71.00 $60.00 $114.00 $51.00 $63.00 $32.00 $10.00 $22.00 $34.00 $11.00 $24.00 $26.00 $9.00 $17.00 $33.00 $11.00 $22.00 $114.00 $32.00 $83.00 $40.00 $12.00 $28.00 $33.00 $10.00 $23.00 $31.00 $9.00 $22.00

$11.00 $27.00 $33.00 $11.00 $23.00 $114.00 $55.00 $60.00 $114.00 $56.00 $58.00 $108.00 $50.00 $58.00 $149.00 $81.00 $69.00 $134.00 $47.00 $87.00 $134.00 $73.00 $61.00 $116.00 $53.00 $63.00 $32.00 $10.00 $22.00 $35.00 $11.00 $24.00 $27.00 $9.00 $18.00 $34.00 $11.00 $23.00 $116.00 $33.00 $83.00 $41.00 $13.00 $29.00 $34.00 $10.00 $24.00 $32.00 $10.00 $22.00

$11.00 $25.00 $30.00 $10.00 $21.00 $106.00 $51.00 $55.00 $106.00 $52.00 $54.00 $100.00 $47.00 $53.00 $139.00 $75.00 $63.00 $125.00 $44.00 $81.00 $124.00 $68.00 $56.00 $107.00 $49.00 $58.00 $30.00 $9.00 $20.00 $32.00 $10.00 $22.00 $25.00 $9.00 $16.00 $31.00 $11.00 $21.00 $108.00 $31.00 $77.00 $38.00 $12.00 $26.00 $31.00 $9.00 $22.00 $29.00 $9.00 $20.00



Locality 04


$11.00 $27.00 $32.00 $10.00 $22.00 $112.00 $53.00 $59.00 $112.00 $54.00 $58.00 $106.00 $49.00 $57.00 $146.00 $78.00 $68.00 $132.00 $46.00 $87.00 $131.00 $71.00 $60.00 $114.00 $51.00 $63.00 $32.00 $10.00 $22.00 $34.00 $11.00 $24.00 $26.00 $9.00 $17.00 $33.00 $11.00 $22.00 $114.00 $32.00 $83.00 $40.00 $12.00 $28.00 $33.00 $10.00 $23.00 $31.00 $9.00 $22.00

$11.00 $27.00 $33.00 $11.00 $23.00 $114.00 $55.00 $60.00 $114.00 $56.00 $58.00 $108.00 $50.00 $58.00 $149.00 $81.00 $69.00 $134.00 $47.00 $87.00 $134.00 $73.00 $61.00 $116.00 $53.00 $63.00 $32.00 $10.00 $22.00 $35.00 $11.00 $24.00 $27.00 $9.00 $18.00 $34.00 $11.00 $23.00 $116.00 $33.00 $83.00 $41.00 $13.00 $29.00 $34.00 $10.00 $24.00 $32.00 $10.00 $22.00

Part C, 286


Radiology CPT Code

2003 MRA


$30.00 $8.00 $21.00 $74.00 NC NC $28.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $54.00 NC NC $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $59.00 $220.00 $342.00 $63.00 $277.00 $375.00 $94.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$33.00 $10.00 $24.00 $105.00 $32.00 $72.00 $28.00 $9.00 $18.00 $31.00 $9.00 $22.00 $38.00 $10.00 $28.00 $115.00 $32.00 $83.00 $28.00 $9.00 $19.00 $33.00 $10.00 $23.00 $34.00 $8.00 $26.00 $175.00 $56.00 $119.00 $240.00 $66.00 $174.00 $298.00 $69.00 $230.00 $351.00 $101.00 $250.00 $365.00 $76.00 $288.00 $434.00 $92.00 $342.00 $537.00 $121.00 $415.00 $255.00 $77.00

$36.00 $10.00 $25.00 $111.00 $34.00 $78.00 $30.00 $10.00 $20.00 $33.00 $10.00 $23.00 $40.00 $10.00 $30.00 $122.00 $33.00 $89.00 $30.00 $10.00 $20.00 $35.00 $10.00 $25.00 $36.00 $8.00 $28.00 $186.00 $58.00 $128.00 $255.00 $68.00 $187.00 $318.00 $71.00 $247.00 $373.00 $104.00 $268.00 $389.00 $79.00 $310.00 $462.00 $95.00 $368.00 $571.00 $125.00 $446.00 $270.00 $79.00

$36.00 $11.00 $26.00 $113.00 $35.00 $78.00 $30.00 $10.00 $20.00 $34.00 $10.00 $24.00 $41.00 $11.00 $31.00 $124.00 $35.00 $90.00 $31.00 $10.00 $21.00 $36.00 $11.00 $25.00 $37.00 $9.00 $28.00 $189.00 $60.00 $128.00 $258.00 $70.00 $188.00 $321.00 $73.00 $248.00 $377.00 $108.00 $270.00 $393.00 $81.00 $311.00 $467.00 $97.00 $369.00 $577.00 $129.00 $448.00 $274.00 $82.00

$33.00 $10.00 $24.00 $105.00 $32.00 $72.00 $28.00 $9.00 $18.00 $31.00 $9.00 $22.00 $38.00 $10.00 $28.00 $115.00 $32.00 $83.00 $28.00 $9.00 $19.00 $33.00 $10.00 $23.00 $34.00 $8.00 $26.00 $175.00 $56.00 $119.00 $240.00 $66.00 $174.00 $298.00 $69.00 $230.00 $351.00 $101.00 $250.00 $365.00 $76.00 $288.00 $434.00 $92.00 $342.00 $537.00 $121.00 $415.00 $255.00 $77.00



Locality 04


$36.00 $10.00 $25.00 $111.00 $34.00 $78.00 $30.00 $10.00 $20.00 $33.00 $10.00 $23.00 $40.00 $10.00 $30.00 $122.00 $33.00 $89.00 $30.00 $10.00 $20.00 $35.00 $10.00 $25.00 $36.00 $8.00 $28.00 $186.00 $58.00 $128.00 $255.00 $68.00 $187.00 $318.00 $71.00 $247.00 $373.00 $104.00 $268.00 $389.00 $79.00 $310.00 $462.00 $95.00 $368.00 $571.00 $125.00 $446.00 $270.00 $79.00

$36.00 $11.00 $26.00 $113.00 $35.00 $78.00 $30.00 $10.00 $20.00 $34.00 $10.00 $24.00 $41.00 $11.00 $31.00 $124.00 $35.00 $90.00 $31.00 $10.00 $21.00 $36.00 $11.00 $25.00 $37.00 $9.00 $28.00 $189.00 $60.00 $128.00 $258.00 $70.00 $188.00 $321.00 $73.00 $248.00 $377.00 $108.00 $270.00 $393.00 $81.00 $311.00 $467.00 $97.00 $369.00 $577.00 $129.00 $448.00 $274.00 $82.00

Part C, 287


Radiology CPT Code

2003 MRA


$413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $513.00 $92.00 $419.00 ------------------------------------------------------------------------------------------------------------------------------------------------$84.00 NC NC ------------------------------------------------$29.00 $8.00 $19.00 $31.00 $9.00 $21.00 $35.00 $11.00 $22.00 $28.00 $8.00 $18.00 $84.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$178.00 $406.00 $92.00 $314.00 $504.00 $121.00 $383.00 $435.00 $96.00 $339.00 $32.00 $11.00 $21.00 $44.00 $13.00 $32.00 $56.00 $16.00 $39.00 $43.00 $13.00 $30.00 $53.00 $17.00 $36.00 $61.00 $18.00 $43.00 $109.00 $32.00 $77.00 $30.00 $9.00 $21.00 $35.00 $11.00 $24.00 $33.00 $9.00 $24.00 $38.00 $11.00 $28.00 $42.00 $13.00 $30.00 $38.00 $10.00 $28.00 $124.00

$191.00 $432.00 $95.00 $338.00 $536.00 $125.00 $411.00 $463.00 $100.00 $364.00 $34.00 $11.00 $23.00 $47.00 $13.00 $34.00 $59.00 $17.00 $42.00 $45.00 $13.00 $32.00 $56.00 $18.00 $38.00 $65.00 $19.00 $46.00 $116.00 $34.00 $83.00 $32.00 $10.00 $22.00 $37.00 $11.00 $26.00 $36.00 $10.00 $26.00 $41.00 $11.00 $30.00 $45.00 $13.00 $32.00 $41.00 $10.00 $31.00 $132.00

$192.00 $437.00 $97.00 $339.00 $541.00 $129.00 $412.00 $468.00 $103.00 $365.00 $35.00 $11.00 $23.00 $48.00 $13.00 $35.00 $60.00 $17.00 $43.00 $46.00 $14.00 $32.00 $57.00 $18.00 $39.00 $66.00 $19.00 $47.00 $118.00 $35.00 $83.00 $33.00 $10.00 $23.00 $38.00 $11.00 $27.00 $36.00 $10.00 $26.00 $42.00 $11.00 $30.00 $46.00 $13.00 $32.00 $42.00 $11.00 $31.00 $134.00

$178.00 $406.00 $92.00 $314.00 $504.00 $121.00 $383.00 $435.00 $96.00 $339.00 $32.00 $11.00 $21.00 $44.00 $13.00 $32.00 $56.00 $16.00 $39.00 $43.00 $13.00 $30.00 $53.00 $17.00 $36.00 $61.00 $18.00 $43.00 $109.00 $32.00 $77.00 $30.00 $9.00 $21.00 $35.00 $11.00 $24.00 $33.00 $9.00 $24.00 $38.00 $11.00 $28.00 $42.00 $13.00 $30.00 $38.00 $10.00 $28.00 $124.00



Locality 04


$191.00 $432.00 $95.00 $338.00 $536.00 $125.00 $411.00 $463.00 $100.00 $364.00 $34.00 $11.00 $23.00 $47.00 $13.00 $34.00 $59.00 $17.00 $42.00 $45.00 $13.00 $32.00 $56.00 $18.00 $38.00 $65.00 $19.00 $46.00 $116.00 $34.00 $83.00 $32.00 $10.00 $22.00 $37.00 $11.00 $26.00 $36.00 $10.00 $26.00 $41.00 $11.00 $30.00 $45.00 $13.00 $32.00 $41.00 $10.00 $31.00 $132.00

$192.00 $437.00 $97.00 $339.00 $541.00 $129.00 $412.00 $468.00 $103.00 $365.00 $35.00 $11.00 $23.00 $48.00 $13.00 $35.00 $60.00 $17.00 $43.00 $46.00 $14.00 $32.00 $57.00 $18.00 $39.00 $66.00 $19.00 $47.00 $118.00 $35.00 $83.00 $33.00 $10.00 $23.00 $38.00 $11.00 $27.00 $36.00 $10.00 $26.00 $42.00 $11.00 $30.00 $46.00 $13.00 $32.00 $42.00 $11.00 $31.00 $134.00

Part C, 288


Radiology CPT Code

2003 MRA


NC NC $29.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $72.00 NC NC $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $26.00 $8.00 $17.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $61.00 $220.00 $341.00 $62.00 $277.00 $379.00 $98.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$32.00 $92.00 $31.00 $9.00 $21.00 $32.00 $9.00 $23.00 $33.00 $10.00 $24.00 $113.00 $32.00 $80.00 $28.00 $9.00 $19.00 $31.00 $9.00 $22.00 $29.00 $9.00 $20.00 $30.00 $8.00 $23.00 $175.00 $56.00 $119.00 $243.00 $66.00 $178.00 $295.00 $68.00 $227.00 $357.00 $107.00 $250.00 $365.00 $76.00 $288.00 $434.00 $91.00 $342.00 $540.00 $121.00 $418.00 $255.00 $77.00 $178.00

$33.00 $99.00 $33.00 $10.00 $23.00 $34.00 $10.00 $25.00 $36.00 $10.00 $25.00 $120.00 $33.00 $86.00 $30.00 $9.00 $21.00 $33.00 $10.00 $23.00 $31.00 $9.00 $22.00 $32.00 $8.00 $25.00 $186.00 $58.00 $128.00 $259.00 $68.00 $191.00 $314.00 $71.00 $243.00 $379.00 $110.00 $269.00 $389.00 $79.00 $310.00 $462.00 $94.00 $368.00 $574.00 $125.00 $449.00 $271.00 $79.00 $192.00

$35.00 $99.00 $33.00 $10.00 $23.00 $35.00 $10.00 $25.00 $36.00 $11.00 $26.00 $121.00 $34.00 $87.00 $31.00 $9.00 $21.00 $34.00 $10.00 $24.00 $32.00 $10.00 $22.00 $33.00 $8.00 $25.00 $189.00 $60.00 $128.00 $262.00 $70.00 $192.00 $317.00 $73.00 $244.00 $384.00 $114.00 $270.00 $393.00 $81.00 $311.00 $466.00 $97.00 $369.00 $580.00 $129.00 $451.00 $275.00 $82.00 $193.00

$32.00 $92.00 $31.00 $9.00 $21.00 $32.00 $9.00 $23.00 $33.00 $10.00 $24.00 $113.00 $32.00 $80.00 $28.00 $9.00 $19.00 $31.00 $9.00 $22.00 $29.00 $9.00 $20.00 $30.00 $8.00 $23.00 $175.00 $56.00 $119.00 $243.00 $66.00 $178.00 $295.00 $68.00 $227.00 $357.00 $107.00 $250.00 $365.00 $76.00 $288.00 $434.00 $91.00 $342.00 $540.00 $121.00 $418.00 $255.00 $77.00 $178.00



Locality 04


$33.00 $99.00 $33.00 $10.00 $23.00 $34.00 $10.00 $25.00 $36.00 $10.00 $25.00 $120.00 $33.00 $86.00 $30.00 $9.00 $21.00 $33.00 $10.00 $23.00 $31.00 $9.00 $22.00 $32.00 $8.00 $25.00 $186.00 $58.00 $128.00 $259.00 $68.00 $191.00 $314.00 $71.00 $243.00 $379.00 $110.00 $269.00 $389.00 $79.00 $310.00 $462.00 $94.00 $368.00 $574.00 $125.00 $449.00 $271.00 $79.00 $192.00

$35.00 $99.00 $33.00 $10.00 $23.00 $35.00 $10.00 $25.00 $36.00 $11.00 $26.00 $121.00 $34.00 $87.00 $31.00 $9.00 $21.00 $34.00 $10.00 $24.00 $32.00 $10.00 $22.00 $33.00 $8.00 $25.00 $189.00 $60.00 $128.00 $262.00 $70.00 $192.00 $317.00 $73.00 $244.00 $384.00 $114.00 $270.00 $393.00 $81.00 $311.00 $466.00 $97.00 $369.00 $580.00 $129.00 $451.00 $275.00 $82.00 $193.00

Part C, 289


Radiology CPT Code

2003 MRA


$579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $515.00 $92.00 $419.00 $29.00 $9.00 $19.00 $33.00 $11.00 $21.00 $37.00 $13.00 $22.00 $44.00 $16.00 $28.00 $274.00 $60.00 $211.00 $322.00 $65.00 $256.00 $390.00 $71.00 $317.00 ------------------------$418.00 $98.00 $315.00 ------------------------------------------------------------------------$498.00 $85.00 $415.00 $587.00 $88.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$410.00 $92.00 $318.00 $506.00 $121.00 $384.00 $431.00 $101.00 $330.00 $26.00 $10.00 $15.00 $38.00 $13.00 $25.00 $41.00 $15.00 $25.00 $48.00 $18.00 $30.00 $162.00 $67.00 $95.00 $249.00 $72.00 $177.00 $282.00 $79.00 $204.00 $419.00 $123.00 $296.00 $331.00 $102.00 $229.00 $218.00 $98.00 $119.00 $335.00 $103.00 $233.00 $380.00 $113.00 $267.00 $358.00 $82.00 $276.00 $487.00 $98.00

$436.00 $95.00 $342.00 $538.00 $125.00 $413.00 $459.00 $105.00 $354.00 $27.00 $11.00 $16.00 $40.00 $13.00 $27.00 $43.00 $16.00 $27.00 $51.00 $19.00 $32.00 $172.00 $69.00 $102.00 $264.00 $74.00 $190.00 $300.00 $82.00 $219.00 $445.00 $127.00 $317.00 $351.00 $105.00 $246.00 $230.00 $102.00 $128.00 $356.00 $106.00 $250.00 $404.00 $117.00 $287.00 $381.00 $85.00 $296.00 $519.00 $101.00

$441.00 $97.00 $343.00 $543.00 $129.00 $415.00 $464.00 $108.00 $356.00 $28.00 $11.00 $17.00 $41.00 $14.00 $27.00 $44.00 $17.00 $27.00 $52.00 $19.00 $33.00 $174.00 $72.00 $103.00 $267.00 $76.00 $191.00 $304.00 $84.00 $219.00 $450.00 $132.00 $319.00 $356.00 $108.00 $247.00 $234.00 $105.00 $129.00 $360.00 $109.00 $251.00 $409.00 $120.00 $288.00 $385.00 $87.00 $298.00 $524.00 $104.00

$410.00 $92.00 $318.00 $506.00 $121.00 $384.00 $431.00 $101.00 $330.00 $26.00 $10.00 $15.00 $38.00 $13.00 $25.00 $41.00 $15.00 $25.00 $48.00 $18.00 $30.00 $162.00 $67.00 $95.00 $249.00 $72.00 $177.00 $282.00 $79.00 $204.00 $419.00 $123.00 $296.00 $331.00 $102.00 $229.00 $218.00 $98.00 $119.00 $335.00 $103.00 $233.00 $380.00 $113.00 $267.00 $358.00 $82.00 $276.00 $487.00 $98.00



Locality 04


$436.00 $95.00 $342.00 $538.00 $125.00 $413.00 $459.00 $105.00 $354.00 $27.00 $11.00 $16.00 $40.00 $13.00 $27.00 $43.00 $16.00 $27.00 $51.00 $19.00 $32.00 $172.00 $69.00 $102.00 $264.00 $74.00 $190.00 $300.00 $82.00 $219.00 $445.00 $127.00 $317.00 $351.00 $105.00 $246.00 $230.00 $102.00 $128.00 $356.00 $106.00 $250.00 $404.00 $117.00 $287.00 $381.00 $85.00 $296.00 $519.00 $101.00

$441.00 $97.00 $343.00 $543.00 $129.00 $415.00 $464.00 $108.00 $356.00 $28.00 $11.00 $17.00 $41.00 $14.00 $27.00 $44.00 $17.00 $27.00 $52.00 $19.00 $33.00 $174.00 $72.00 $103.00 $267.00 $76.00 $191.00 $304.00 $84.00 $219.00 $450.00 $132.00 $319.00 $356.00 $108.00 $247.00 $234.00 $105.00 $129.00 $360.00 $109.00 $251.00 $409.00 $120.00 $288.00 $385.00 $87.00 $298.00 $524.00 $104.00

Part C, 290


Radiology CPT Code

2003 MRA


$496.00 $1,037.00 $114.00 $919.00 $514.00 $92.00 $419.00 $73.00 NC NC $63.00 $18.00 $44.00 $68.00 $23.00 $44.00 $77.00 $27.00 $48.00 $160.00 NC NC $91.00 $35.00 $55.00 $91.00 $35.00 $56.00 $137.00 $46.00 $89.00 $97.00 $35.00 $61.00 $99.00 $35.00 $63.00 $144.00 $46.00 $96.00 $73.00 $23.00 $48.00 $85.00 $34.00 $48.00 $82.00 $25.00 $56.00 ---------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$389.00 $544.00 $128.00 $417.00 $433.00 $101.00 $332.00 $397.00 $27.00 $371.00 $83.00 $20.00 $63.00 $95.00 $26.00 $69.00 $136.00 $30.00 $106.00 --------$72.00 BR $122.00 $39.00 $83.00 $127.00 $39.00 $88.00 $185.00 $51.00 $133.00 $137.00 $39.00 $98.00 $145.00 $39.00 $106.00 $198.00 $51.00 $146.00 $112.00 $26.00 $85.00 $241.00 $39.00 $202.00 $231.00 $28.00 $202.00 $255.00

$418.00 $579.00 $132.00 $447.00 $461.00 $104.00 $357.00 $425.00 $27.00 $398.00 $89.00 $21.00 $68.00 $102.00 $27.00 $75.00 $145.00 $31.00 $114.00 --------$77.00 BR $130.00 $40.00 $89.00 $135.00 $40.00 $94.00 $196.00 $53.00 $143.00 $146.00 $40.00 $105.00 $155.00 $40.00 $114.00 $210.00 $53.00 $157.00 $119.00 $27.00 $92.00 $258.00 $40.00 $217.00 $247.00 $29.00 $217.00 $268.00

$420.00 $585.00 $136.00 $449.00 $466.00 $107.00 $358.00 $428.00 $28.00 $399.00 $90.00 $21.00 $69.00 $103.00 $28.00 $75.00 $146.00 $32.00 $114.00 --------$84.00 BR $131.00 $42.00 $90.00 $137.00 $42.00 $95.00 $198.00 $55.00 $144.00 $148.00 $42.00 $106.00 $157.00 $42.00 $115.00 $213.00 $55.00 $158.00 $120.00 $28.00 $92.00 $260.00 $42.00 $218.00 $249.00 $30.00 $218.00 $273.00

$389.00 $544.00 $128.00 $417.00 $433.00 $101.00 $332.00 $397.00 $27.00 $371.00 $83.00 $20.00 $63.00 $95.00 $26.00 $69.00 $136.00 $30.00 $106.00 --------$72.00 BR $122.00 $39.00 $83.00 $127.00 $39.00 $88.00 $185.00 $51.00 $133.00 $137.00 $39.00 $98.00 $145.00 $39.00 $106.00 $198.00 $51.00 $146.00 $112.00 $26.00 $85.00 $241.00 $39.00 $202.00 $231.00 $28.00 $202.00 $255.00



Locality 04


$418.00 $579.00 $132.00 $447.00 $461.00 $104.00 $357.00 $425.00 $27.00 $398.00 $89.00 $21.00 $68.00 $102.00 $27.00 $75.00 $145.00 $31.00 $114.00 --------$77.00 BR $130.00 $40.00 $89.00 $135.00 $40.00 $94.00 $196.00 $53.00 $143.00 $146.00 $40.00 $105.00 $155.00 $40.00 $114.00 $210.00 $53.00 $157.00 $119.00 $27.00 $92.00 $258.00 $40.00 $217.00 $247.00 $29.00 $217.00 $268.00

$420.00 $585.00 $136.00 $449.00 $466.00 $107.00 $358.00 $428.00 $28.00 $399.00 $90.00 $21.00 $69.00 $103.00 $28.00 $75.00 $146.00 $32.00 $114.00 --------$84.00 BR $131.00 $42.00 $90.00 $137.00 $42.00 $95.00 $198.00 $55.00 $144.00 $148.00 $42.00 $106.00 $157.00 $42.00 $115.00 $213.00 $55.00 $158.00 $120.00 $28.00 $92.00 $260.00 $42.00 $218.00 $249.00 $30.00 $218.00 $273.00

Part C, 291


Radiology CPT Code

2003 MRA


----------------------------------------------------------------$100.00 $35.00 $64.00 $136.00 $50.00 $84.00 $201.00 $103.00 $95.00 $44.00 $16.00 $28.00 $31.00 NC NC BR NC NC $155.00 NC NC $155.00 NC NC $165.00 NC NC $121.00 NC NC $137.00 NC NC $145.00 NC NC $274.00 NC NC $89.00 $24.00 $63.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$136.00 $119.00 $390.00 $141.00 $249.00 $806.00 $126.00 $680.00 $145.00 $39.00 $106.00 $229.00 $56.00 $173.00 $224.00 $115.00 $109.00 $75.00 $18.00 $57.00 --------$21.00 BR --------$12.00 BR --------$40.00 BR --------$40.00 BR --------$51.00 BR --------$30.00 BR --------$44.00 BR --------$32.00 BR --------$48.00 BR $118.00 $28.00 $91.00






Locality 04




Part C, 292


Radiology CPT Code

2003 MRA


$98.00 $24.00 $72.00 $105.00 $24.00 $79.00 $117.00 $18.00 $97.00 $68.00 NC NC $48.00 NC NC $62.00 NC NC $101.00 NC NC $60.00 NC NC $75.00 NC NC $74.00 NC NC $146.00 NC NC $57.00 $17.00 $39.00 ------------------------------------------------$68.00 NC NC $150.00 NC NC $88.00 $32.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$116.00 $27.00 $89.00 $147.00 $28.00 $119.00 $390.00 $20.00 $371.00 $390.00 $20.00 $371.00 $41.00 $18.00 $23.00 $87.00 $20.00 $67.00 $431.00 $60.00 $371.00 $221.00 $19.00 $202.00 $88.00 $19.00 $69.00 $400.00 $30.00 $371.00 $99.00 $29.00 $70.00 $40.00 $19.00 $21.00 $458.00 $169.00 $288.00 $251.00 $101.00 $150.00 $80.00 $21.00 $59.00 --------$33.00 BR $237.00 $35.00

$124.00 $28.00 $96.00 $156.00 $29.00 $128.00 $418.00 $20.00 $398.00 $418.00 $20.00 $398.00 $43.00 $19.00 $25.00 $93.00 $21.00 $72.00 $460.00 $62.00 $398.00 $236.00 $19.00 $217.00 $93.00 $19.00 $74.00 $428.00 $31.00 $398.00 $105.00 $30.00 $75.00 $42.00 $20.00 $22.00 $485.00 $175.00 $310.00 $265.00 $104.00 $161.00 $86.00 $22.00 $64.00 --------$34.00 BR $253.00 $36.00

$125.00 $29.00 $96.00 $158.00 $30.00 $128.00 $420.00 $20.00 $399.00 $420.00 $21.00 $399.00 $44.00 $19.00 $25.00 $93.00 $21.00 $72.00 $462.00 $63.00 $399.00 $238.00 $20.00 $218.00 $94.00 $20.00 $75.00 $431.00 $32.00 $399.00 $106.00 $31.00 $76.00 $43.00 $21.00 $23.00 $492.00 $180.00 $311.00 $269.00 $107.00 $162.00 $87.00 $23.00 $64.00 --------$36.00 BR $256.00 $38.00

$116.00 $27.00 $89.00 $147.00 $28.00 $119.00 $390.00 $20.00 $371.00 $390.00 $20.00 $371.00 $41.00 $18.00 $23.00 $87.00 $20.00 $67.00 $431.00 $60.00 $371.00 $221.00 $19.00 $202.00 $88.00 $19.00 $69.00 $400.00 $30.00 $371.00 $99.00 $29.00 $70.00 $40.00 $19.00 $21.00 $458.00 $169.00 $288.00 $251.00 $101.00 $150.00 $80.00 $21.00 $59.00 --------$33.00 BR $237.00 $35.00



Locality 04


$124.00 $28.00 $96.00 $156.00 $29.00 $128.00 $418.00 $20.00 $398.00 $418.00 $20.00 $398.00 $43.00 $19.00 $25.00 $93.00 $21.00 $72.00 $460.00 $62.00 $398.00 $236.00 $19.00 $217.00 $93.00 $19.00 $74.00 $428.00 $31.00 $398.00 $105.00 $30.00 $75.00 $42.00 $20.00 $22.00 $485.00 $175.00 $310.00 $265.00 $104.00 $161.00 $86.00 $22.00 $64.00 --------$34.00 BR $253.00 $36.00

$125.00 $29.00 $96.00 $158.00 $30.00 $128.00 $420.00 $20.00 $399.00 $420.00 $21.00 $399.00 $44.00 $19.00 $25.00 $93.00 $21.00 $72.00 $462.00 $63.00 $399.00 $238.00 $20.00 $218.00 $94.00 $20.00 $75.00 $431.00 $32.00 $399.00 $106.00 $31.00 $76.00 $43.00 $21.00 $23.00 $492.00 $180.00 $311.00 $269.00 $107.00 $162.00 $87.00 $23.00 $64.00 --------$36.00 BR $256.00 $38.00

Part C, 293


Radiology CPT Code

2003 MRA


$55.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$497.00 NC NC $183.00 NC NC $143.00 NC NC $239.00 NC NC $445.00 NC NC $540.00 NC NC $587.00 NC NC $194.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$202.00 $344.00 $130.00 $214.00 $470.00 $160.00 $310.00 $456.00 $143.00 $313.00 $540.00 $164.00 $376.00 $59.00 $14.00 $45.00 $46.00 $32.00 $14.00 $306.00 $97.00 $209.00 $391.00 $142.00 $250.00 $382.00 $133.00 $249.00 $212.00 $28.00 $185.00 $152.00 $63.00 $88.00 $152.00 $64.00 $88.00 $188.00 $100.00 $88.00 $384.00 $134.00 $250.00 $183.00 $73.00 $110.00 $269.00 $131.00 $138.00 $179.00

$217.00 $364.00 $134.00 $230.00 $497.00 $165.00 $333.00 $483.00 $148.00 $336.00 $573.00 $169.00 $404.00 $62.00 $14.00 $48.00 $48.00 $33.00 $15.00 $325.00 $101.00 $224.00 $414.00 $146.00 $268.00 $405.00 $137.00 $268.00 $227.00 $29.00 $198.00 $161.00 $66.00 $95.00 $161.00 $67.00 $94.00 $199.00 $105.00 $94.00 $407.00 $139.00 $269.00 $195.00 $76.00 $119.00 $286.00 $137.00 $148.00 $191.00

$218.00 $368.00 $137.00 $231.00 $502.00 $168.00 $334.00 $489.00 $152.00 $337.00 $578.00 $173.00 $406.00 $63.00 $14.00 $48.00 $50.00 $34.00 $15.00 $329.00 $103.00 $226.00 $420.00 $150.00 $270.00 $410.00 $141.00 $269.00 $229.00 $30.00 $199.00 $164.00 $69.00 $95.00 $166.00 $71.00 $95.00 $205.00 $110.00 $95.00 $413.00 $143.00 $270.00 $200.00 $81.00 $120.00 $296.00 $146.00 $149.00 $195.00

$202.00 $344.00 $130.00 $214.00 $470.00 $160.00 $310.00 $456.00 $143.00 $313.00 $540.00 $164.00 $376.00 $59.00 $14.00 $45.00 $46.00 $32.00 $14.00 $306.00 $97.00 $209.00 $391.00 $142.00 $250.00 $382.00 $133.00 $249.00 $212.00 $28.00 $185.00 $152.00 $63.00 $88.00 $152.00 $64.00 $88.00 $188.00 $100.00 $88.00 $384.00 $134.00 $250.00 $183.00 $73.00 $110.00 $269.00 $131.00 $138.00 $179.00



Locality 04


$217.00 $364.00 $134.00 $230.00 $497.00 $165.00 $333.00 $483.00 $148.00 $336.00 $573.00 $169.00 $404.00 $62.00 $14.00 $48.00 $48.00 $33.00 $15.00 $325.00 $101.00 $224.00 $414.00 $146.00 $268.00 $405.00 $137.00 $268.00 $227.00 $29.00 $198.00 $161.00 $66.00 $95.00 $161.00 $67.00 $94.00 $199.00 $105.00 $94.00 $407.00 $139.00 $269.00 $195.00 $76.00 $119.00 $286.00 $137.00 $148.00 $191.00

$218.00 $368.00 $137.00 $231.00 $502.00 $168.00 $334.00 $489.00 $152.00 $337.00 $578.00 $173.00 $406.00 $63.00 $14.00 $48.00 $50.00 $34.00 $15.00 $329.00 $103.00 $226.00 $420.00 $150.00 $270.00 $410.00 $141.00 $269.00 $229.00 $30.00 $199.00 $164.00 $69.00 $95.00 $166.00 $71.00 $95.00 $205.00 $110.00 $95.00 $413.00 $143.00 $270.00 $200.00 $81.00 $120.00 $296.00 $146.00 $149.00 $195.00

Part C, 294


Radiology CPT Code

2003 MRA


NC NC $293.00 NC NC $530.00 NC NC $530.00 NC NC $540.00 NC NC $530.00 NC NC $540.00 NC NC $253.00 NC NC $530.00 NC NC $183.00 NC NC $80.00 NC NC ------------------------$245.00 NC NC $264.00 NC NC $271.00 NC NC $289.00 NC NC $54.00 NC NC

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$64.00 $114.00 $205.00 $74.00 $132.00 $163.00 $63.00 $100.00 $187.00 $64.00 $123.00 $200.00 $71.00 $129.00 $176.00 $63.00 $113.00 $165.00 $72.00 $94.00 $186.00 $91.00 $95.00 $166.00 $63.00 $102.00 $183.00 $64.00 $119.00 $95.00 $20.00 $75.00 $353.00 $99.00 $254.00 $254.00 $52.00 $202.00 $769.00 $66.00 $703.00 $749.00 $46.00 $703.00 $2,930.00 $66.00 $2,863.00 $107.00 $27.00 $80.00

$67.00 $123.00 $218.00 $77.00 $142.00 $173.00 $65.00 $108.00 $198.00 $66.00 $132.00 $212.00 $73.00 $138.00 $186.00 $65.00 $121.00 $175.00 $74.00 $100.00 $196.00 $94.00 $102.00 $176.00 $65.00 $110.00 $195.00 $67.00 $128.00 $101.00 $21.00 $81.00 $377.00 $104.00 $273.00 $272.00 $55.00 $217.00 $823.00 $68.00 $755.00 $802.00 $47.00 $755.00 $3,141.00 $69.00 $3,072.00 $114.00 $28.00 $86.00

$71.00 $124.00 $224.00 $81.00 $143.00 $176.00 $67.00 $108.00 $201.00 $68.00 $133.00 $214.00 $75.00 $140.00 $191.00 $69.00 $122.00 $178.00 $77.00 $101.00 $200.00 $98.00 $102.00 $179.00 $68.00 $111.00 $200.00 $72.00 $128.00 $103.00 $22.00 $81.00 $386.00 $112.00 $274.00 $278.00 $60.00 $218.00 $827.00 $70.00 $757.00 $806.00 $49.00 $757.00 $3,152.00 $71.00 $3,082.00 $116.00 $29.00 $87.00

$64.00 $114.00 $205.00 $74.00 $132.00 $163.00 $63.00 $100.00 $187.00 $64.00 $123.00 $200.00 $71.00 $129.00 $176.00 $63.00 $113.00 $165.00 $72.00 $94.00 $186.00 $91.00 $95.00 $166.00 $63.00 $102.00 $183.00 $64.00 $119.00 $95.00 $20.00 $75.00 $353.00 $99.00 $254.00 $254.00 $52.00 $202.00 $769.00 $66.00 $703.00 $749.00 $46.00 $703.00 $2,930.00 $66.00 $2,863.00 $107.00 $27.00 $80.00



Locality 04


$67.00 $123.00 $218.00 $77.00 $142.00 $173.00 $65.00 $108.00 $198.00 $66.00 $132.00 $212.00 $73.00 $138.00 $186.00 $65.00 $121.00 $175.00 $74.00 $100.00 $196.00 $94.00 $102.00 $176.00 $65.00 $110.00 $195.00 $67.00 $128.00 $101.00 $21.00 $81.00 $377.00 $104.00 $273.00 $272.00 $55.00 $217.00 $823.00 $68.00 $755.00 $802.00 $47.00 $755.00 $3,141.00 $69.00 $3,072.00 $114.00 $28.00 $86.00

$71.00 $124.00 $224.00 $81.00 $143.00 $176.00 $67.00 $108.00 $201.00 $68.00 $133.00 $214.00 $75.00 $140.00 $191.00 $69.00 $122.00 $178.00 $77.00 $101.00 $200.00 $98.00 $102.00 $179.00 $68.00 $111.00 $200.00 $72.00 $128.00 $103.00 $22.00 $81.00 $386.00 $112.00 $274.00 $278.00 $60.00 $218.00 $827.00 $70.00 $757.00 $806.00 $49.00 $757.00 $3,152.00 $71.00 $3,082.00 $116.00 $29.00 $87.00

Part C, 295


Radiology CPT Code

2003 MRA


$530.00 NC NC $72.00 NC NC $111.00 NC NC $194.00 NC NC $530.00 NC NC $54.00 NC NC $549.00 NC NC $531.00 NC NC $549.00 NC NC $531.00 NC NC $531.00 NC NC $530.00 NC NC $72.00 NC NC $546.00 NC NC $546.00 NC NC $530.00 NC NC $530.00 NC

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$2,928.00 $65.00 $2,863.00 $125.00 $39.00 $86.00 $150.00 $59.00 $91.00 $150.00 $64.00 $85.00 $152.00 $65.00 $88.00 $154.00 $63.00 $91.00 $181.00 $83.00 $99.00 $162.00 $64.00 $97.00 $197.00 $84.00 $113.00 $156.00 $63.00 $93.00 $161.00 $64.00 $97.00 $153.00 $60.00 $93.00 $154.00 $41.00 $114.00 $173.00 $78.00 $95.00 $174.00 $79.00 $95.00 $157.00 $62.00 $95.00 $158.00 $63.00

$3,139.00 $67.00 $3,072.00 $133.00 $41.00 $92.00 $159.00 $62.00 $98.00 $159.00 $67.00 $92.00 $162.00 $68.00 $94.00 $163.00 $65.00 $98.00 $193.00 $87.00 $106.00 $171.00 $66.00 $105.00 $208.00 $86.00 $121.00 $166.00 $66.00 $100.00 $170.00 $66.00 $104.00 $162.00 $62.00 $100.00 $164.00 $42.00 $122.00 $183.00 $81.00 $102.00 $184.00 $81.00 $102.00 $166.00 $64.00 $102.00 $168.00 $65.00

$3,151.00 $69.00 $3,082.00 $136.00 $43.00 $93.00 $163.00 $64.00 $98.00 $164.00 $71.00 $92.00 $167.00 $72.00 $95.00 $167.00 $69.00 $99.00 $199.00 $92.00 $107.00 $173.00 $68.00 $105.00 $211.00 $89.00 $122.00 $169.00 $68.00 $101.00 $173.00 $68.00 $104.00 $165.00 $65.00 $100.00 $166.00 $43.00 $123.00 $186.00 $84.00 $102.00 $187.00 $84.00 $103.00 $169.00 $66.00 $103.00 $170.00 $67.00

$2,928.00 $65.00 $2,863.00 $125.00 $39.00 $86.00 $150.00 $59.00 $91.00 $150.00 $64.00 $85.00 $152.00 $65.00 $88.00 $154.00 $63.00 $91.00 $181.00 $83.00 $99.00 $162.00 $64.00 $97.00 $197.00 $84.00 $113.00 $156.00 $63.00 $93.00 $161.00 $64.00 $97.00 $153.00 $60.00 $93.00 $154.00 $41.00 $114.00 $173.00 $78.00 $95.00 $174.00 $79.00 $95.00 $157.00 $62.00 $95.00 $158.00 $63.00



Locality 04


$3,139.00 $67.00 $3,072.00 $133.00 $41.00 $92.00 $159.00 $62.00 $98.00 $159.00 $67.00 $92.00 $162.00 $68.00 $94.00 $163.00 $65.00 $98.00 $193.00 $87.00 $106.00 $171.00 $66.00 $105.00 $208.00 $86.00 $121.00 $166.00 $66.00 $100.00 $170.00 $66.00 $104.00 $162.00 $62.00 $100.00 $164.00 $42.00 $122.00 $183.00 $81.00 $102.00 $184.00 $81.00 $102.00 $166.00 $64.00 $102.00 $168.00 $65.00

$3,151.00 $69.00 $3,082.00 $136.00 $43.00 $93.00 $163.00 $64.00 $98.00 $164.00 $71.00 $92.00 $167.00 $72.00 $95.00 $167.00 $69.00 $99.00 $199.00 $92.00 $107.00 $173.00 $68.00 $105.00 $211.00 $89.00 $122.00 $169.00 $68.00 $101.00 $173.00 $68.00 $104.00 $165.00 $65.00 $100.00 $166.00 $43.00 $123.00 $186.00 $84.00 $102.00 $187.00 $84.00 $103.00 $169.00 $66.00 $103.00 $170.00 $67.00

Part C, 296


Radiology CPT Code

2003 MRA


NC $499.00 NC NC $972.00 NC NC $124.00 $84.00 $39.00 $98.00 NC NC $93.00 NC NC BR NC NC BR NC NC BR NC NC ------------------------------------------------------------------------------------------------$618.00 NC NC $333.00 NC NC $659.00 NC NC $333.00 NC NC $475.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$95.00 $128.00 $30.00 $98.00 --------$75.00 BR $799.00 $96.00 $703.00 $190.00 $27.00 $163.00 $78.00 $21.00 $56.00 --------$260.00 BR --------$79.00 BR --------$132.00 BR BR $406.00 BR BR $349.00 BR BR $232.00 BR BR $203.00 BR $152.00 $30.00 $122.00 $96.00 $21.00 $75.00 $187.00 $73.00 $114.00 $95.00 $20.00 $74.00 ---------






Locality 04




Part C, 297


Radiology CPT Code

2003 MRA

75970-26 75970-TC 75978 75978-26 75978-TC 75984 75984-26 75984-TC 75989 75989-26 75989-TC 76000 76000-26 76000-TC 76001 76001-26 76001-TC 76080 76080-26 76080-TC 76098 76098-26 76098-TC 76100 76100-26 76100-TC 76101 76101-26 76101-TC 76102 76102-26 76102-TC 76120 76120-26 76120-TC 76125 76125-26 76125-TC 76140 76376 76376-26 76376-TC 76377 76377-26 76377-TC 76380 76380-26 76380-TC 76390 76390-26

NC NC $617.00 NC NC $110.00 NC NC $180.00 NC NC $58.00 $8.00 $48.00 $134.00 $34.00 $97.00 $67.00 NC NC $23.00 $8.00 $15.00 $77.00 $30.00 $46.00 $94.00 $36.00 $59.00 $95.00 $30.00 $65.00 $157.00 $56.00 $102.00 $49.00 $17.00 $33.00 $31.00 ------------------------------------------------$182.00 $50.00 $131.00 $493.00 $71.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$45.00 BR $150.00 $30.00 $120.00 $115.00 $40.00 $76.00 $132.00 $66.00 $66.00 $51.00 $10.00 $41.00 --------$41.00 --------$60.00 $30.00 $31.00 $18.00 $9.00 $9.00 $100.00 $36.00 $64.00 $141.00 $38.00 $104.00 $187.00 $38.00 $149.00 $90.00 $22.00 $68.00 --------$16.00 ----------------$25.00 $11.00 $14.00 $78.00 $45.00 $33.00 $120.00 $55.00 $64.00 $475.00 $78.00

$47.00 BR $161.00 $32.00 $129.00 $122.00 $41.00 $81.00 $139.00 $68.00 $71.00 $55.00 $10.00 $44.00 --------$43.00 --------$64.00 $31.00 $33.00 $19.00 $9.00 $10.00 $106.00 $37.00 $69.00 $150.00 $39.00 $111.00 $200.00 $40.00 $160.00 $96.00 $22.00 $73.00 --------$17.00 ----------------$27.00 $11.00 $15.00 $82.00 $46.00 $36.00 $126.00 $57.00 $69.00 $506.00 $80.00

$49.00 BR $163.00 $34.00 $130.00 $124.00 $42.00 $82.00 $142.00 $70.00 $71.00 $56.00 $11.00 $45.00 --------$45.00 --------$65.00 $32.00 $34.00 $20.00 $10.00 $10.00 $108.00 $39.00 $70.00 $152.00 $40.00 $112.00 $202.00 $41.00 $161.00 $97.00 $23.00 $74.00 --------$18.00 ----------------$27.00 $12.00 $16.00 $84.00 $48.00 $36.00 $129.00 $59.00 $70.00 $509.00 $81.00

$45.00 BR $150.00 $30.00 $120.00 $115.00 $40.00 $76.00 $132.00 $66.00 $66.00 $51.00 $10.00 $41.00 --------$41.00 --------$60.00 $30.00 $31.00 $18.00 $9.00 $9.00 $100.00 $36.00 $64.00 $141.00 $38.00 $104.00 $187.00 $38.00 $149.00 $90.00 $22.00 $68.00 --------$16.00 ----------------$25.00 $11.00 $14.00 $78.00 $45.00 $33.00 $120.00 $55.00 $64.00 $475.00 $78.00



Locality 04


$47.00 BR $161.00 $32.00 $129.00 $122.00 $41.00 $81.00 $139.00 $68.00 $71.00 $55.00 $10.00 $44.00 --------$43.00 --------$64.00 $31.00 $33.00 $19.00 $9.00 $10.00 $106.00 $37.00 $69.00 $150.00 $39.00 $111.00 $200.00 $40.00 $160.00 $96.00 $22.00 $73.00 --------$17.00 ----------------$27.00 $11.00 $15.00 $82.00 $46.00 $36.00 $126.00 $57.00 $69.00 $506.00 $80.00

$49.00 BR $163.00 $34.00 $130.00 $124.00 $42.00 $82.00 $142.00 $70.00 $71.00 $56.00 $11.00 $45.00 --------$45.00 --------$65.00 $32.00 $34.00 $20.00 $10.00 $10.00 $108.00 $39.00 $70.00 $152.00 $40.00 $112.00 $202.00 $41.00 $161.00 $97.00 $23.00 $74.00 --------$18.00 ----------------$27.00 $12.00 $16.00 $84.00 $48.00 $36.00 $129.00 $59.00 $70.00 $509.00 $81.00

Part C, 298


Radiology CPT Code

2003 MRA


$419.00 BR BR BR BR BR BR BR BR BR BR BR BR $88.00 $33.00 $53.00 ------------------------$96.00 $48.00 $48.00 $96.00 $36.00 $60.00 $96.00 $36.00 $60.00 ------------------------$99.00 $37.00 $63.00 $88.00 $31.00 $53.00 $86.00 $31.00 $53.00 $83.00 $31.00 $54.00 $78.00 $28.00 $48.00 ---------------------------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$398.00 ----------------$64.00 ----------------$64.00 ----------------$288.00 ------------------------$129.00 $36.00 $92.00 $185.00 $98.00 $87.00 $110.00 $58.00 $52.00 $101.00 $58.00 $42.00 $103.00 $39.00 $64.00 $17.00 $11.00 $6.00 $85.00 $34.00 $51.00 $91.00 $34.00 $56.00 $86.00 $36.00 $50.00 $126.00 $32.00 $94.00 $96.00 $30.00 $65.00 $117.00 $41.00 $76.00 $96.00

$427.00 ----------------$69.00 ----------------$69.00 ----------------$309.00 ------------------------$137.00 $38.00 $99.00 $194.00 $101.00 $93.00 $115.00 $60.00 $55.00 $106.00 $60.00 $46.00 $109.00 $40.00 $68.00 $18.00 $11.00 $6.00 $90.00 $35.00 $55.00 $96.00 $35.00 $61.00 $91.00 $37.00 $54.00 $134.00 $33.00 $101.00 $101.00 $31.00 $70.00 $124.00 $42.00 $81.00 $102.00

$428.00 ----------------$69.00 ----------------$69.00 ----------------$311.00 ------------------------$139.00 $39.00 $100.00 $195.00 $102.00 $94.00 $116.00 $60.00 $56.00 $107.00 $60.00 $46.00 $110.00 $41.00 $69.00 $18.00 $12.00 $7.00 $91.00 $36.00 $55.00 $97.00 $36.00 $61.00 $92.00 $37.00 $54.00 $135.00 $34.00 $102.00 $103.00 $32.00 $71.00 $126.00 $44.00 $82.00 $104.00

$398.00 ----------------$64.00 ----------------$64.00 ----------------$288.00 ------------------------$129.00 $36.00 $92.00 $185.00 $98.00 $87.00 $110.00 $58.00 $52.00 $101.00 $58.00 $42.00 $103.00 $39.00 $64.00 $17.00 $11.00 $6.00 $85.00 $34.00 $51.00 $91.00 $34.00 $56.00 $86.00 $36.00 $50.00 $126.00 $32.00 $94.00 $96.00 $30.00 $65.00 $117.00 $41.00 $76.00 $96.00



Locality 04


$427.00 ----------------$69.00 ----------------$69.00 ----------------$309.00 ------------------------$137.00 $38.00 $99.00 $194.00 $101.00 $93.00 $115.00 $60.00 $55.00 $106.00 $60.00 $46.00 $109.00 $40.00 $68.00 $18.00 $11.00 $6.00 $90.00 $35.00 $55.00 $96.00 $35.00 $61.00 $91.00 $37.00 $54.00 $134.00 $33.00 $101.00 $101.00 $31.00 $70.00 $124.00 $42.00 $81.00 $102.00

$428.00 ----------------$69.00 ----------------$69.00 ----------------$311.00 ------------------------$139.00 $39.00 $100.00 $195.00 $102.00 $94.00 $116.00 $60.00 $56.00 $107.00 $60.00 $46.00 $110.00 $41.00 $69.00 $18.00 $12.00 $7.00 $91.00 $36.00 $55.00 $97.00 $36.00 $61.00 $92.00 $37.00 $54.00 $135.00 $34.00 $102.00 $103.00 $32.00 $71.00 $126.00 $44.00 $82.00 $104.00

Part C, 299


Radiology CPT Code

2003 MRA


----------------$116.00 $42.00 $73.00 $84.00 $30.00 $53.00 $112.00 $38.00 $73.00 $84.00 $30.00 $53.00 ------------------------$112.00 $61.00 $54.00 $93.00 $51.00 $42.00 $73.00 $43.00 $30.00 $131.00 $51.00 $79.00 $252.00 $100.00 $151.00 $243.00 $100.00 $142.00 $145.00 $94.00 $51.00 ------------------------------------------------$88.00 $33.00 $53.00 $72.00 $30.00 $41.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$38.00 $58.00 $133.00 $45.00 $88.00 $99.00 $33.00 $66.00 $123.00 $41.00 $82.00 $63.00 $32.00 $31.00 $170.00 $43.00 $127.00 $155.00 $69.00 $86.00 $134.00 $56.00 $78.00 $72.00 $48.00 $24.00 $155.00 $57.00 $98.00 $103.00 $57.00 $46.00 $201.00 $111.00 $90.00 $227.00 $104.00 $123.00 $133.00 $69.00 $64.00 $90.00 $58.00 $32.00 $92.00 $37.00 $55.00 $126.00 $50.00 $77.00

$40.00 $62.00 $141.00 $47.00 $94.00 $105.00 $34.00 $71.00 $131.00 $43.00 $88.00 $67.00 $33.00 $34.00 $181.00 $44.00 $137.00 $166.00 $73.00 $93.00 $142.00 $58.00 $84.00 $75.00 $50.00 $26.00 $164.00 $59.00 $105.00 $108.00 $59.00 $49.00 $212.00 $116.00 $97.00 $240.00 $109.00 $132.00 $141.00 $72.00 $69.00 $95.00 $61.00 $34.00 $98.00 $38.00 $59.00 $134.00 $52.00 $82.00

$41.00 $63.00 $143.00 $48.00 $95.00 $107.00 $35.00 $72.00 $133.00 $44.00 $88.00 $68.00 $34.00 $34.00 $183.00 $45.00 $137.00 $171.00 $78.00 $93.00 $145.00 $60.00 $84.00 $77.00 $52.00 $26.00 $167.00 $61.00 $106.00 $111.00 $61.00 $50.00 $218.00 $121.00 $98.00 $246.00 $113.00 $132.00 $145.00 $75.00 $70.00 $98.00 $64.00 $35.00 $99.00 $39.00 $60.00 $137.00 $54.00 $83.00

$38.00 $58.00 $133.00 $45.00 $88.00 $99.00 $33.00 $66.00 $123.00 $41.00 $82.00 $63.00 $32.00 $31.00 $170.00 $43.00 $127.00 $155.00 $69.00 $86.00 $134.00 $56.00 $78.00 $72.00 $48.00 $24.00 $155.00 $57.00 $98.00 $103.00 $57.00 $46.00 $201.00 $111.00 $90.00 $227.00 $104.00 $123.00 $133.00 $69.00 $64.00 $90.00 $58.00 $32.00 $92.00 $37.00 $55.00 $126.00 $50.00 $77.00



Locality 04


$40.00 $62.00 $141.00 $47.00 $94.00 $105.00 $34.00 $71.00 $131.00 $43.00 $88.00 $67.00 $33.00 $34.00 $181.00 $44.00 $137.00 $166.00 $73.00 $93.00 $142.00 $58.00 $84.00 $75.00 $50.00 $26.00 $164.00 $59.00 $105.00 $108.00 $59.00 $49.00 $212.00 $116.00 $97.00 $240.00 $109.00 $132.00 $141.00 $72.00 $69.00 $95.00 $61.00 $34.00 $98.00 $38.00 $59.00 $134.00 $52.00 $82.00

$41.00 $63.00 $143.00 $48.00 $95.00 $107.00 $35.00 $72.00 $133.00 $44.00 $88.00 $68.00 $34.00 $34.00 $183.00 $45.00 $137.00 $171.00 $78.00 $93.00 $145.00 $60.00 $84.00 $77.00 $52.00 $26.00 $167.00 $61.00 $106.00 $111.00 $61.00 $50.00 $218.00 $121.00 $98.00 $246.00 $113.00 $132.00 $145.00 $75.00 $70.00 $98.00 $64.00 $35.00 $99.00 $39.00 $60.00 $137.00 $54.00 $83.00

Part C, 300


Radiology CPT Code

2003 MRA


$96.00 $39.00 $57.00 $105.00 $40.00 $60.00 $101.00 $40.00 $60.00 ------------------------------------------------$160.00 $65.00 $73.00 $71.00 $46.00 $27.00 $97.00 $35.00 $65.00 $72.00 $29.00 $42.00 $93.00 $35.00 $57.00 $95.00 $37.00 $57.00 $93.00 $35.00 $57.00 $59.00 $19.00 $39.00 $90.00 $33.00 $57.00 $93.00 $36.00 $57.00 $151.00 $68.00 $80.00 -----------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$106.00 $43.00 $63.00 $134.00 $62.00 $72.00 $97.00 $45.00 $53.00 $52.00 $29.00 $23.00 $102.00 $41.00 $61.00 $301.00 $94.00 $206.00 $177.00 $46.00 $131.00 $83.00 $32.00 $50.00 $59.00 $32.00 $27.00 $133.00 $39.00 $94.00 $129.00 $42.00 $87.00 $119.00 $39.00 $81.00 $52.00 $28.00 $24.00 $74.00 $36.00 $38.00 $102.00 $37.00 $65.00 $183.00 $87.00 $96.00 $124.00 $35.00

$113.00 $45.00 $68.00 $142.00 $64.00 $78.00 $103.00 $47.00 $57.00 $55.00 $30.00 $25.00 $108.00 $43.00 $66.00 $319.00 $98.00 $222.00 $188.00 $48.00 $140.00 $88.00 $33.00 $54.00 $62.00 $33.00 $29.00 $141.00 $40.00 $100.00 $137.00 $43.00 $94.00 $127.00 $40.00 $87.00 $55.00 $29.00 $26.00 $78.00 $37.00 $41.00 $108.00 $38.00 $70.00 $193.00 $89.00 $103.00 $132.00 $36.00

$115.00 $46.00 $69.00 $146.00 $67.00 $79.00 $106.00 $48.00 $57.00 $57.00 $31.00 $25.00 $111.00 $44.00 $66.00 $324.00 $101.00 $223.00 $190.00 $49.00 $141.00 $89.00 $34.00 $55.00 $64.00 $35.00 $29.00 $143.00 $42.00 $101.00 $139.00 $45.00 $95.00 $129.00 $41.00 $87.00 $57.00 $30.00 $27.00 $80.00 $38.00 $41.00 $109.00 $39.00 $70.00 $195.00 $91.00 $104.00 $133.00 $37.00

$106.00 $43.00 $63.00 $134.00 $62.00 $72.00 $97.00 $45.00 $53.00 $52.00 $29.00 $23.00 $102.00 $41.00 $61.00 $301.00 $94.00 $206.00 $177.00 $46.00 $131.00 $83.00 $32.00 $50.00 $59.00 $32.00 $27.00 $133.00 $39.00 $94.00 $129.00 $42.00 $87.00 $119.00 $39.00 $81.00 $52.00 $28.00 $24.00 $74.00 $36.00 $38.00 $102.00 $37.00 $65.00 $183.00 $87.00 $96.00 $124.00 $35.00



Locality 04


$113.00 $45.00 $68.00 $142.00 $64.00 $78.00 $103.00 $47.00 $57.00 $55.00 $30.00 $25.00 $108.00 $43.00 $66.00 $319.00 $98.00 $222.00 $188.00 $48.00 $140.00 $88.00 $33.00 $54.00 $62.00 $33.00 $29.00 $141.00 $40.00 $100.00 $137.00 $43.00 $94.00 $127.00 $40.00 $87.00 $55.00 $29.00 $26.00 $78.00 $37.00 $41.00 $108.00 $38.00 $70.00 $193.00 $89.00 $103.00 $132.00 $36.00

$115.00 $46.00 $69.00 $146.00 $67.00 $79.00 $106.00 $48.00 $57.00 $57.00 $31.00 $25.00 $111.00 $44.00 $66.00 $324.00 $101.00 $223.00 $190.00 $49.00 $141.00 $89.00 $34.00 $55.00 $64.00 $35.00 $29.00 $143.00 $42.00 $101.00 $139.00 $45.00 $95.00 $129.00 $41.00 $87.00 $57.00 $30.00 $27.00 $80.00 $38.00 $41.00 $109.00 $39.00 $70.00 $195.00 $91.00 $104.00 $133.00 $37.00

Part C, 301


Radiology CPT Code

2003 MRA


--------------------------------$93.00 NC NC $93.00 NC NC $341.00 $102.00 $236.00 ------------------------------------------------$128.00 NC NC $92.00 NC NC $93.00 NC NC $78.00 NC NC $77.00 NC NC $281.00 $84.00 $208.00 $60.00 $20.00 $39.00 $99.00 NC NC $34.00 $3.00 $31.00 ------------------------BR

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$89.00 $40.00 $28.00 $12.00 --------$37.00 BR --------$37.00 BR $299.00 $113.00 $186.00 $34.00 $16.00 $18.00 BR $118.00 BR --------$78.00 BR $67.00 $38.00 $29.00 --------$39.00 BR $36.00 $22.00 $14.00 $76.00 $34.00 $42.00 $99.00 $74.00 $25.00 $100.00 $22.00 $79.00 $210.00 $48.00 $162.00 $8.00 $3.00 $5.00 BR $73.00 BR ---------






Locality 04




Part C, 302


Radiology CPT Code

2003 MRA

76999-26 76999-TC 77001 77001-26 77001-TC 77002 77002-26 77002-TC 77003 77003-26 77003-TC 77011 77011-26 77011-TC 77012 77012-26 77012-TC 77013-26 77013-TC 77014 77014-26 77014-TC 77021 77021-26 77021-TC 77022 77022-26 77022-TC 77051 77051-26 77051-TC 77052 77052-26 77052-TC 77053 77053-26 77053-TC 77054 77054-26 77054-TC 77055 77055-26 77055-TC 77056 77056-26 77056-TC 77057 77057-26 77057-TC 77058

BR BR -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

----------------$76.00 $21.00 $54.00 $101.00 $32.00 $69.00 $93.00 $34.00 $59.00 $240.00 $70.00 $170.00 $136.00 $65.00 $71.00 $220.00 BR $128.00 $49.00 $79.00 $433.00 $85.00 $348.00 BR $239.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $63.00 $20.00 $43.00 $83.00 $26.00 $57.00 $97.00 $39.00 $58.00 $125.00 $49.00 $76.00 $89.00 $39.00 $50.00 $570.00

----------------$81.00 $22.00 $58.00 $107.00 $33.00 $74.00 $98.00 $35.00 $63.00 $255.00 $73.00 $183.00 $144.00 $67.00 $77.00 $227.00 BR $135.00 $50.00 $85.00 $461.00 $87.00 $374.00 BR $247.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $67.00 $21.00 $46.00 $88.00 $27.00 $62.00 $103.00 $41.00 $62.00 $132.00 $51.00 $81.00 $94.00 $41.00 $53.00 $609.00

----------------$82.00 $23.00 $59.00 $109.00 $34.00 $75.00 $100.00 $36.00 $64.00 $259.00 $75.00 $184.00 $146.00 $69.00 $77.00 $234.00 BR $137.00 $52.00 $85.00 $466.00 $90.00 $375.00 BR $255.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $68.00 $21.00 $47.00 $90.00 $28.00 $62.00 $104.00 $42.00 $62.00 $134.00 $52.00 $82.00 $96.00 $42.00 $54.00 $614.00

----------------$76.00 $21.00 $54.00 $101.00 $32.00 $69.00 $93.00 $34.00 $59.00 $240.00 $70.00 $170.00 $136.00 $65.00 $71.00 $220.00 BR $128.00 $49.00 $79.00 $433.00 $85.00 $348.00 BR $239.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $63.00 $20.00 $43.00 $83.00 $26.00 $57.00 $97.00 $39.00 $58.00 $125.00 $49.00 $76.00 $89.00 $39.00 $50.00 $570.00



Locality 04


----------------$81.00 $22.00 $58.00 $107.00 $33.00 $74.00 $98.00 $35.00 $63.00 $255.00 $73.00 $183.00 $144.00 $67.00 $77.00 $227.00 BR $135.00 $50.00 $85.00 $461.00 $87.00 $374.00 BR $247.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $67.00 $21.00 $46.00 $88.00 $27.00 $62.00 $103.00 $41.00 $62.00 $132.00 $51.00 $81.00 $94.00 $41.00 $53.00 $609.00

----------------$82.00 $23.00 $59.00 $109.00 $34.00 $75.00 $100.00 $36.00 $64.00 $259.00 $75.00 $184.00 $146.00 $69.00 $77.00 $234.00 BR $137.00 $52.00 $85.00 $466.00 $90.00 $375.00 BR $255.00 BR $9.00 $3.00 $6.00 $9.00 $3.00 $6.00 $68.00 $21.00 $47.00 $90.00 $28.00 $62.00 $104.00 $42.00 $62.00 $134.00 $52.00 $82.00 $96.00 $42.00 $54.00 $614.00

Part C, 303


Radiology CPT Code

2003 MRA

77058-26 77058-TC 77059 77059-26 77059-TC 77063 77063-26 77063-TC 77071 77072 77072-26 77072-TC 77073 77073-26 77073-TC 77074 77074-26 77074-TC 77075 77075-26 77075-TC 77077 77077-26 77077-TC 77078 77078-26 77078-TC 77080 77080-26 77080-TC 77081 77081-26 77081-TC 77084 77084-26 77084-TC 77085 77085-26 77085-TC 77086 77086-26 77086-TC 77261 77262 77263 77280 77280-26 77280-TC 77285 77285-26

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$73.00 $110.00 $163.00 $166.00 $36.00 $130.00 $264.00 $53.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$92.00 $479.00 $570.00 $92.00 $479.00 $60.00 $34.00 $27.00 $53.00 $25.00 $11.00 $15.00 $39.00 $16.00 $23.00 $70.00 $26.00 $44.00 $94.00 $30.00 $64.00 $41.00 $18.00 $22.00 $78.00 $14.00 $64.00 $44.00 $11.00 $33.00 $30.00 $12.00 $18.00 $379.00 $90.00 $288.00 $61.00 $17.00 $44.00 $38.00 $10.00 $28.00 $84.00 $126.00 $185.00 $293.00 $40.00 $253.00 $462.00 $61.00

$95.00 $514.00 $609.00 $95.00 $514.00 $63.00 $35.00 $29.00 $57.00 $27.00 $11.00 $16.00 $41.00 $17.00 $25.00 $74.00 $27.00 $47.00 $100.00 $31.00 $69.00 $43.00 $19.00 $24.00 $83.00 $14.00 $69.00 $47.00 $12.00 $36.00 $32.00 $13.00 $20.00 $403.00 $93.00 $310.00 $65.00 $18.00 $47.00 $41.00 $10.00 $31.00 $88.00 $131.00 $192.00 $313.00 $41.00 $272.00 $494.00 $63.00

$97.00 $516.00 $614.00 $97.00 $516.00 $64.00 $36.00 $29.00 $59.00 $27.00 $11.00 $16.00 $42.00 $17.00 $25.00 $75.00 $28.00 $48.00 $102.00 $32.00 $69.00 $44.00 $19.00 $25.00 $84.00 $14.00 $70.00 $48.00 $12.00 $36.00 $33.00 $13.00 $20.00 $407.00 $96.00 $311.00 $66.00 $19.00 $47.00 $42.00 $11.00 $31.00 $90.00 $136.00 $200.00 $315.00 $42.00 $273.00 $497.00 $64.00

$92.00 $479.00 $570.00 $92.00 $479.00 $60.00 $34.00 $27.00 $53.00 $25.00 $11.00 $15.00 $39.00 $16.00 $23.00 $70.00 $26.00 $44.00 $94.00 $30.00 $64.00 $41.00 $18.00 $22.00 $78.00 $14.00 $64.00 $44.00 $11.00 $33.00 $30.00 $12.00 $18.00 $379.00 $90.00 $288.00 $61.00 $17.00 $44.00 $38.00 $10.00 $28.00 $84.00 $126.00 $185.00 $293.00 $40.00 $253.00 $462.00 $61.00



Locality 04


$95.00 $514.00 $609.00 $95.00 $514.00 $63.00 $35.00 $29.00 $57.00 $27.00 $11.00 $16.00 $41.00 $17.00 $25.00 $74.00 $27.00 $47.00 $100.00 $31.00 $69.00 $43.00 $19.00 $24.00 $83.00 $14.00 $69.00 $47.00 $12.00 $36.00 $32.00 $13.00 $20.00 $403.00 $93.00 $310.00 $65.00 $18.00 $47.00 $41.00 $10.00 $31.00 $88.00 $131.00 $192.00 $313.00 $41.00 $272.00 $494.00 $63.00

$97.00 $516.00 $614.00 $97.00 $516.00 $64.00 $36.00 $29.00 $59.00 $27.00 $11.00 $16.00 $42.00 $17.00 $25.00 $75.00 $28.00 $48.00 $102.00 $32.00 $69.00 $44.00 $19.00 $25.00 $84.00 $14.00 $70.00 $48.00 $12.00 $36.00 $33.00 $13.00 $20.00 $407.00 $96.00 $311.00 $66.00 $19.00 $47.00 $42.00 $11.00 $31.00 $90.00 $136.00 $200.00 $315.00 $42.00 $273.00 $497.00 $64.00

Part C, 304


Radiology CPT Code

2003 MRA


$209.00 $325.00 $79.00 $243.00 ------------------------$1,287.00 $232.00 $1,046.00 BR BR BR $87.00 $36.00 $52.00 $1,473.00 $415.00 $1,046.00 ------------------------------------------------------------------------------------------------------------------------$200.00 $48.00 $150.00 $64.00 $45.00 $18.00 $78.00 $27.00 $50.00 $115.00 $43.00 $70.00 $187.00 $63.00 $121.00 $111.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$402.00 $553.00 $90.00 $463.00 $502.00 $115.00 $387.00 $534.00 $246.00 $288.00 ------------------------$73.00 $36.00 $37.00 $2,106.00 $459.00 $1,648.00 $163.00 $81.00 $82.00 $315.00 $166.00 $149.00 $205.00 $81.00 $124.00 $267.00 $105.00 $162.00 $386.00 $166.00 $219.00 $101.00 $55.00 $47.00 $70.00 $50.00 $20.00 $90.00 $31.00 $58.00 $59.00 $48.00 $10.00 $166.00 $71.00 $95.00 $86.00

$431.00 $590.00 $93.00 $497.00 $534.00 $119.00 $416.00 $563.00 $254.00 $309.00 ------------------------$77.00 $37.00 $40.00 $2,244.00 $473.00 $1,771.00 $172.00 $83.00 $89.00 $331.00 $171.00 $160.00 $217.00 $83.00 $134.00 $283.00 $109.00 $174.00 $407.00 $171.00 $236.00 $107.00 $56.00 $50.00 $73.00 $52.00 $22.00 $95.00 $32.00 $63.00 $61.00 $50.00 $11.00 $175.00 $73.00 $102.00 $93.00

$433.00 $594.00 $95.00 $499.00 $539.00 $122.00 $417.00 $571.00 $259.00 $312.00 ------------------------$78.00 $38.00 $40.00 $2,268.00 $484.00 $1,784.00 $174.00 $85.00 $89.00 $336.00 $175.00 $161.00 $220.00 $85.00 $135.00 $287.00 $111.00 $176.00 $414.00 $175.00 $239.00 $108.00 $58.00 $51.00 $75.00 $53.00 $22.00 $96.00 $33.00 $63.00 $63.00 $51.00 $12.00 $177.00 $75.00 $102.00 $95.00

$402.00 $553.00 $90.00 $463.00 $502.00 $115.00 $387.00 $534.00 $246.00 $288.00 ------------------------$73.00 $36.00 $37.00 $2,106.00 $459.00 $1,648.00 $163.00 $81.00 $82.00 $315.00 $166.00 $149.00 $205.00 $81.00 $124.00 $267.00 $105.00 $162.00 $386.00 $166.00 $219.00 $101.00 $55.00 $47.00 $70.00 $50.00 $20.00 $90.00 $31.00 $58.00 $59.00 $48.00 $10.00 $166.00 $71.00 $95.00 $86.00



Locality 04


$431.00 $590.00 $93.00 $497.00 $534.00 $119.00 $416.00 $563.00 $254.00 $309.00 ------------------------$77.00 $37.00 $40.00 $2,244.00 $473.00 $1,771.00 $172.00 $83.00 $89.00 $331.00 $171.00 $160.00 $217.00 $83.00 $134.00 $283.00 $109.00 $174.00 $407.00 $171.00 $236.00 $107.00 $56.00 $50.00 $73.00 $52.00 $22.00 $95.00 $32.00 $63.00 $61.00 $50.00 $11.00 $175.00 $73.00 $102.00 $93.00

$433.00 $594.00 $95.00 $499.00 $539.00 $122.00 $417.00 $571.00 $259.00 $312.00 ------------------------$78.00 $38.00 $40.00 $2,268.00 $484.00 $1,784.00 $174.00 $85.00 $89.00 $336.00 $175.00 $161.00 $220.00 $85.00 $135.00 $287.00 $111.00 $176.00 $414.00 $175.00 $239.00 $108.00 $58.00 $51.00 $75.00 $53.00 $22.00 $96.00 $33.00 $63.00 $63.00 $51.00 $12.00 $177.00 $75.00 $102.00 $95.00

Part C, 305


Radiology CPT Code

2003 MRA

77338 77338-26 77338-TC 77370 77371 77372 77373 77399 77399-26 77399-TC 77401 77402 77407 77412 77417 77422 77423 77427 77431 77432 77435 77469 77470 77470-26 77470-TC 77499 77499-26 77499-TC 77520 77522 77523 77525 77600 77600-26 77600-TC 77605 77605-26 77605-TC 77610 77610-26 77610-TC 77615 77615-26 77615-TC 77620 77620-26 77620-TC 77750 77750-26 77750-TC

------------------------$130.00 ------------------------BR BR BR $66.00 $66.00 $78.00 $87.00 $21.00 ----------------$166.00 $95.00 $417.00 ----------------$527.00 $106.00 $417.00 BR BR BR BR BR BR BR $196.00 $80.00 $113.00 $263.00 $108.00 $151.00 $195.00 $79.00 $113.00 $262.00 $106.00 $151.00 $196.00 $80.00 $113.00 $299.00 $248.00 $49.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$552.00 $246.00 $306.00 $132.00 BR $1,147.00 $1,458.00 ------------------------$26.00 ------------------------$12.00 BR BR $207.00 $114.00 $467.00 $704.00 $358.00 $172.00 $120.00 $52.00 --------------------------------------------------------$453.00 $91.00 $362.00 $862.00 $133.00 $729.00 $1,067.00 $99.00 $968.00 $1,140.00 $119.00 $1,021.00 $414.00 $90.00 $324.00 $408.00 $286.00 $122.00

$583.00 $254.00 $329.00 $143.00 BR $1,232.00 $1,566.00 ------------------------$28.00 ------------------------$13.00 BR BR $215.00 $118.00 $485.00 $732.00 $373.00 $179.00 $124.00 $56.00 --------------------------------------------------------$483.00 $94.00 $389.00 $923.00 $141.00 $782.00 $1,145.00 $106.00 $1,039.00 $1,219.00 $123.00 $1,096.00 $441.00 $93.00 $348.00 $426.00 $295.00 $131.00

$592.00 $259.00 $332.00 $147.00 BR $1,241.00 $1,577.00 ------------------------$28.00 ------------------------$13.00 BR BR $223.00 $122.00 $503.00 $759.00 $385.00 $183.00 $127.00 $56.00 --------------------------------------------------------$488.00 $97.00 $391.00 $938.00 $152.00 $786.00 $1,158.00 $115.00 $1,043.00 $1,228.00 $126.00 $1,102.00 $445.00 $95.00 $351.00 $435.00 $302.00 $132.00

$552.00 $246.00 $306.00 $132.00 BR $1,147.00 $1,458.00 ------------------------$26.00 ------------------------$12.00 BR BR $207.00 $114.00 $467.00 $704.00 $358.00 $172.00 $120.00 $52.00 --------------------------------------------------------$453.00 $91.00 $362.00 $862.00 $133.00 $729.00 $1,067.00 $99.00 $968.00 $1,140.00 $119.00 $1,021.00 $414.00 $90.00 $324.00 $408.00 $286.00 $122.00



Locality 04


$583.00 $254.00 $329.00 $143.00 BR $1,232.00 $1,566.00 ------------------------$28.00 ------------------------$13.00 BR BR $215.00 $118.00 $485.00 $732.00 $373.00 $179.00 $124.00 $56.00 --------------------------------------------------------$483.00 $94.00 $389.00 $923.00 $141.00 $782.00 $1,145.00 $106.00 $1,039.00 $1,219.00 $123.00 $1,096.00 $441.00 $93.00 $348.00 $426.00 $295.00 $131.00

$592.00 $259.00 $332.00 $147.00 BR $1,241.00 $1,577.00 ------------------------$28.00 ------------------------$13.00 BR BR $223.00 $122.00 $503.00 $759.00 $385.00 $183.00 $127.00 $56.00 --------------------------------------------------------$488.00 $97.00 $391.00 $938.00 $152.00 $786.00 $1,158.00 $115.00 $1,043.00 $1,228.00 $126.00 $1,102.00 $445.00 $95.00 $351.00 $435.00 $302.00 $132.00

Part C, 306


Radiology CPT Code

2003 MRA


$284.00 $188.00 $93.00 $427.00 $289.00 $135.00 $605.00 $435.00 $167.00 ------------------------------------------------------------------------------------------------------------------------$764.00 $568.00 $192.00 $74.00 $57.00 $16.00 $72.00 $53.00 $18.00 BR BR BR ------------------------------------------------------------------------$132.00 $34.00 $96.00 $173.00 $42.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$425.00 $219.00 $206.00 $567.00 $330.00 $237.00 $804.00 $497.00 $307.00 $243.00 $61.00 $182.00 $380.00 $80.00 $300.00 $347.00 $112.00 $235.00 $647.00 $218.00 $429.00 $987.00 $310.00 $678.00 $852.00 $458.00 $395.00 $130.00 $66.00 $64.00 $16.00 ----------------------------------------$88.00 $11.00 $77.00 $212.00 $21.00 $191.00 $268.00 $28.00 $240.00 $244.00 $37.00 $208.00 $309.00 $38.00

$448.00 $226.00 $222.00 $595.00 $341.00 $255.00 $843.00 $513.00 $330.00 $259.00 $63.00 $196.00 $405.00 $83.00 $322.00 $368.00 $115.00 $253.00 $686.00 $225.00 $461.00 $1,048.00 $319.00 $729.00 $897.00 $472.00 $425.00 $137.00 $68.00 $69.00 $17.00 ----------------------------------------$94.00 $11.00 $83.00 $226.00 $21.00 $205.00 $287.00 $29.00 $258.00 $261.00 $38.00 $223.00 $330.00 $39.00

$456.00 $232.00 $224.00 $606.00 $349.00 $257.00 $859.00 $525.00 $334.00 $262.00 $64.00 $197.00 $409.00 $85.00 $325.00 $373.00 $118.00 $255.00 $694.00 $230.00 $464.00 $1,061.00 $327.00 $734.00 $913.00 $483.00 $430.00 $139.00 $70.00 $70.00 $18.00 ----------------------------------------$95.00 $11.00 $84.00 $229.00 $22.00 $207.00 $289.00 $30.00 $260.00 $263.00 $39.00 $225.00 $333.00 $39.00

$425.00 $219.00 $206.00 $567.00 $330.00 $237.00 $804.00 $497.00 $307.00 $243.00 $61.00 $182.00 $380.00 $80.00 $300.00 $347.00 $112.00 $235.00 $647.00 $218.00 $429.00 $987.00 $310.00 $678.00 $852.00 $458.00 $395.00 $130.00 $66.00 $64.00 $16.00 ----------------------------------------$88.00 $11.00 $77.00 $212.00 $21.00 $191.00 $268.00 $28.00 $240.00 $244.00 $37.00 $208.00 $309.00 $38.00



Locality 04


$448.00 $226.00 $222.00 $595.00 $341.00 $255.00 $843.00 $513.00 $330.00 $259.00 $63.00 $196.00 $405.00 $83.00 $322.00 $368.00 $115.00 $253.00 $686.00 $225.00 $461.00 $1,048.00 $319.00 $729.00 $897.00 $472.00 $425.00 $137.00 $68.00 $69.00 $17.00 ----------------------------------------$94.00 $11.00 $83.00 $226.00 $21.00 $205.00 $287.00 $29.00 $258.00 $261.00 $38.00 $223.00 $330.00 $39.00

$456.00 $232.00 $224.00 $606.00 $349.00 $257.00 $859.00 $525.00 $334.00 $262.00 $64.00 $197.00 $409.00 $85.00 $325.00 $373.00 $118.00 $255.00 $694.00 $230.00 $464.00 $1,061.00 $327.00 $734.00 $913.00 $483.00 $430.00 $139.00 $70.00 $70.00 $18.00 ----------------------------------------$95.00 $11.00 $84.00 $229.00 $22.00 $207.00 $289.00 $30.00 $260.00 $263.00 $39.00 $225.00 $333.00 $39.00

Part C, 307


Radiology CPT Code

2003 MRA


$130.00 $248.00 $44.00 $202.00 $35.00 $30.00 $5.00 $112.00 $36.00 $68.00 ------------------------------------------------$242.00 $38.00 $202.00 BR BR BR $106.00 $28.00 $77.00 $158.00 $39.00 $118.00 $194.00 $41.00 $152.00 $45.00 $9.00 $35.00 $108.00 $11.00 $96.00 $78.00 $11.00 $65.00 $125.00 $16.00 $108.00 $196.00 $22.00 $171.00 $139.00 $32.00 $106.00 $216.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$271.00 $347.00 $47.00 $300.00 $93.00 $31.00 $62.00 $332.00 $44.00 $289.00 $398.00 $66.00 $332.00 $459.00 $86.00 $373.00 $473.00 $39.00 $434.00 ------------------------$188.00 $30.00 $158.00 $247.00 $41.00 $206.00 $272.00 $43.00 $229.00 $104.00 $11.00 $93.00 $107.00 $12.00 $95.00 $104.00 $13.00 $91.00 $113.00 $18.00 $95.00 $109.00 $24.00 $85.00 $187.00 $34.00 $153.00 $387.00

$292.00 $371.00 $48.00 $323.00 $99.00 $32.00 $67.00 $355.00 $45.00 $310.00 $424.00 $68.00 $356.00 $489.00 $88.00 $401.00 $507.00 $41.00 $466.00 ------------------------$201.00 $31.00 $170.00 $264.00 $42.00 $222.00 $291.00 $44.00 $246.00 $112.00 $11.00 $101.00 $114.00 $13.00 $102.00 $112.00 $13.00 $98.00 $121.00 $19.00 $103.00 $116.00 $25.00 $91.00 $199.00 $35.00 $165.00 $414.00

$294.00 $374.00 $49.00 $325.00 $100.00 $33.00 $68.00 $358.00 $46.00 $312.00 $429.00 $70.00 $359.00 $494.00 $91.00 $403.00 $511.00 $41.00 $469.00 ------------------------$204.00 $32.00 $172.00 $267.00 $43.00 $223.00 $293.00 $46.00 $248.00 $113.00 $11.00 $102.00 $116.00 $13.00 $103.00 $113.00 $14.00 $99.00 $123.00 $19.00 $104.00 $118.00 $25.00 $92.00 $202.00 $35.00 $166.00 $417.00

$271.00 $347.00 $47.00 $300.00 $93.00 $31.00 $62.00 $332.00 $44.00 $289.00 $398.00 $66.00 $332.00 $459.00 $86.00 $373.00 $473.00 $39.00 $434.00 ------------------------$188.00 $30.00 $158.00 $247.00 $41.00 $206.00 $272.00 $43.00 $229.00 $104.00 $11.00 $93.00 $107.00 $12.00 $95.00 $104.00 $13.00 $91.00 $113.00 $18.00 $95.00 $109.00 $24.00 $85.00 $187.00 $34.00 $153.00 $387.00



Locality 04


$292.00 $371.00 $48.00 $323.00 $99.00 $32.00 $67.00 $355.00 $45.00 $310.00 $424.00 $68.00 $356.00 $489.00 $88.00 $401.00 $507.00 $41.00 $466.00 ------------------------$201.00 $31.00 $170.00 $264.00 $42.00 $222.00 $291.00 $44.00 $246.00 $112.00 $11.00 $101.00 $114.00 $13.00 $102.00 $112.00 $13.00 $98.00 $121.00 $19.00 $103.00 $116.00 $25.00 $91.00 $199.00 $35.00 $165.00 $414.00

$294.00 $374.00 $49.00 $325.00 $100.00 $33.00 $68.00 $358.00 $46.00 $312.00 $429.00 $70.00 $359.00 $494.00 $91.00 $403.00 $511.00 $41.00 $469.00 ------------------------$204.00 $32.00 $172.00 $267.00 $43.00 $223.00 $293.00 $46.00 $248.00 $113.00 $11.00 $102.00 $116.00 $13.00 $103.00 $113.00 $14.00 $99.00 $123.00 $19.00 $104.00 $118.00 $25.00 $92.00 $202.00 $35.00 $166.00 $417.00

Part C, 308


Radiology CPT Code

2003 MRA


$33.00 $182.00 $179.00 $31.00 $147.00 $110.00 $20.00 $88.00 $272.00 $57.00 $214.00 $307.00 $31.00 $274.00 $216.00 $49.00 $152.00 BR BR BR $112.00 $22.00 $88.00 $135.00 $26.00 $108.00 $259.00 $36.00 $220.00 $265.00 $46.00 $214.00 $135.00 $24.00 $109.00 $160.00 $29.00 $130.00 ------------------------------------------------$106.00 $23.00 $82.00 $146.00 $27.00 $118.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$36.00 $351.00 $152.00 $34.00 $118.00 $235.00 $22.00 $212.00 $435.00 $60.00 $374.00 $187.00 $34.00 $153.00 $396.00 $66.00 $329.00 ------------------------$208.00 $24.00 $185.00 $224.00 $27.00 $197.00 $235.00 $38.00 $197.00 $380.00 $52.00 $328.00 $216.00 $27.00 $189.00 $140.00 $31.00 $109.00 $368.00 $41.00 $327.00 $401.00 $50.00 $351.00 $157.00 $21.00 $135.00 $145.00 $30.00 $115.00

$37.00 $377.00 $162.00 $35.00 $127.00 $251.00 $23.00 $228.00 $464.00 $62.00 $402.00 $199.00 $35.00 $165.00 $422.00 $69.00 $354.00 ------------------------$223.00 $24.00 $198.00 $239.00 $28.00 $212.00 $251.00 $39.00 $212.00 $406.00 $54.00 $352.00 $231.00 $28.00 $203.00 $149.00 $32.00 $118.00 $394.00 $42.00 $351.00 $429.00 $52.00 $377.00 $167.00 $22.00 $146.00 $155.00 $31.00 $124.00

$38.00 $379.00 $164.00 $36.00 $128.00 $253.00 $24.00 $230.00 $468.00 $63.00 $405.00 $202.00 $35.00 $166.00 $427.00 $71.00 $356.00 ------------------------$225.00 $25.00 $200.00 $241.00 $28.00 $213.00 $253.00 $40.00 $213.00 $410.00 $56.00 $354.00 $233.00 $29.00 $204.00 $152.00 $33.00 $119.00 $397.00 $44.00 $353.00 $432.00 $53.00 $379.00 $169.00 $22.00 $147.00 $157.00 $32.00 $125.00

$36.00 $351.00 $152.00 $34.00 $118.00 $235.00 $22.00 $212.00 $435.00 $60.00 $374.00 $187.00 $34.00 $153.00 $396.00 $66.00 $329.00 ------------------------$208.00 $24.00 $185.00 $224.00 $27.00 $197.00 $235.00 $38.00 $197.00 $380.00 $52.00 $328.00 $216.00 $27.00 $189.00 $140.00 $31.00 $109.00 $368.00 $41.00 $327.00 $401.00 $50.00 $351.00 $157.00 $21.00 $135.00 $145.00 $30.00 $115.00



Locality 04


$37.00 $377.00 $162.00 $35.00 $127.00 $251.00 $23.00 $228.00 $464.00 $62.00 $402.00 $199.00 $35.00 $165.00 $422.00 $69.00 $354.00 ------------------------$223.00 $24.00 $198.00 $239.00 $28.00 $212.00 $251.00 $39.00 $212.00 $406.00 $54.00 $352.00 $231.00 $28.00 $203.00 $149.00 $32.00 $118.00 $394.00 $42.00 $351.00 $429.00 $52.00 $377.00 $167.00 $22.00 $146.00 $155.00 $31.00 $124.00

$38.00 $379.00 $164.00 $36.00 $128.00 $253.00 $24.00 $230.00 $468.00 $63.00 $405.00 $202.00 $35.00 $166.00 $427.00 $71.00 $356.00 ------------------------$225.00 $25.00 $200.00 $241.00 $28.00 $213.00 $253.00 $40.00 $213.00 $410.00 $56.00 $354.00 $233.00 $29.00 $204.00 $152.00 $33.00 $119.00 $397.00 $44.00 $353.00 $432.00 $53.00 $379.00 $169.00 $22.00 $147.00 $157.00 $32.00 $125.00

Part C, 309


Radiology CPT Code

2003 MRA

78232 78232-26 78232-TC 78258 78258-26 78258-TC 78261 78261-26 78261-TC 78262 78262-26 78262-TC 78264 78264-26 78264-TC 78265 78265-26 78265-TC 78266 78266-26 78266-TC 78267 78268 78270 78270-26 78270-TC 78271 78271-26 78271-TC 78272 78272-26 78272-TC 78278 78278-26 78278-TC 78282 78282-26 78282-TC 78290 78290-26 78290-TC 78291 78291-26 78291-TC 78299 78299-26 78299-TC 78300 78300-26 78300-TC

$157.00 $23.00 $132.00 $146.00 $38.00 $108.00 $190.00 $36.00 $152.00 $195.00 $35.00 $159.00 $195.00 $40.00 $154.00 ------------------------------------------------BR BR $68.00 $10.00 $58.00 $72.00 $10.00 $61.00 $100.00 $14.00 $87.00 $234.00 $50.00 $182.00 BR $19.00 BR $149.00 $35.00 $113.00 $161.00 $45.00 $114.00 BR BR BR $125.00 $32.00 $93.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$110.00 $22.00 $88.00 $246.00 $41.00 $205.00 $276.00 $38.00 $237.00 $271.00 $37.00 $234.00 $371.00 $41.00 $330.00 $405.00 $54.00 $351.00 $525.00 $60.00 $465.00 ----------------$112.00 $12.00 $100.00 $100.00 $11.00 $89.00 $107.00 $15.00 $92.00 $387.00 $55.00 $333.00 $372.00 $21.00 $350.00 $370.00 $38.00 $332.00 $280.00 $47.00 $233.00 ------------------------$201.00 $35.00 $166.00

$117.00 $22.00 $95.00 $263.00 $42.00 $221.00 $295.00 $40.00 $255.00 $290.00 $38.00 $252.00 $397.00 $42.00 $354.00 $433.00 $56.00 $377.00 $562.00 $62.00 $500.00 ----------------$120.00 $12.00 $108.00 $107.00 $12.00 $95.00 $115.00 $15.00 $99.00 $414.00 $57.00 $357.00 $398.00 $22.00 $376.00 $396.00 $39.00 $357.00 $299.00 $49.00 $250.00 ------------------------$215.00 $36.00 $178.00

$118.00 $23.00 $96.00 $266.00 $44.00 $222.00 $298.00 $41.00 $257.00 $292.00 $39.00 $253.00 $400.00 $44.00 $357.00 $437.00 $57.00 $380.00 $566.00 $64.00 $502.00 ----------------$122.00 $13.00 $109.00 $109.00 $12.00 $97.00 $116.00 $16.00 $101.00 $418.00 $58.00 $360.00 $400.00 $23.00 $377.00 $400.00 $40.00 $359.00 $301.00 $50.00 $252.00 ------------------------$218.00 $38.00 $180.00

$110.00 $22.00 $88.00 $246.00 $41.00 $205.00 $276.00 $38.00 $237.00 $271.00 $37.00 $234.00 $371.00 $41.00 $330.00 $405.00 $54.00 $351.00 $525.00 $60.00 $465.00 ----------------$112.00 $12.00 $100.00 $100.00 $11.00 $89.00 $107.00 $15.00 $92.00 $387.00 $55.00 $333.00 $372.00 $21.00 $350.00 $370.00 $38.00 $332.00 $280.00 $47.00 $233.00 ------------------------$201.00 $35.00 $166.00



Locality 04


$117.00 $22.00 $95.00 $263.00 $42.00 $221.00 $295.00 $40.00 $255.00 $290.00 $38.00 $252.00 $397.00 $42.00 $354.00 $433.00 $56.00 $377.00 $562.00 $62.00 $500.00 ----------------$120.00 $12.00 $108.00 $107.00 $12.00 $95.00 $115.00 $15.00 $99.00 $414.00 $57.00 $357.00 $398.00 $22.00 $376.00 $396.00 $39.00 $357.00 $299.00 $49.00 $250.00 ------------------------$215.00 $36.00 $178.00

$118.00 $23.00 $96.00 $266.00 $44.00 $222.00 $298.00 $41.00 $257.00 $292.00 $39.00 $253.00 $400.00 $44.00 $357.00 $437.00 $57.00 $380.00 $566.00 $64.00 $502.00 ----------------$122.00 $13.00 $109.00 $109.00 $12.00 $97.00 $116.00 $16.00 $101.00 $418.00 $58.00 $360.00 $400.00 $23.00 $377.00 $400.00 $40.00 $359.00 $301.00 $50.00 $252.00 ------------------------$218.00 $38.00 $180.00

Part C, 310


Radiology CPT Code

2003 MRA

78305 78305-26 78305-TC 78306 78306-26 78306-TC 78315 78315-26 78315-TC 78320 78320-26 78320-TC 78350 78350-26 78350-TC 78351 78399 78399-26 78399-TC 78414 78414-26 78414-TC 78428 78428-26 78428-TC 78445 78445-26 78445-TC 78451 78451-26 78451-TC 78452 78452-26 78452-TC 78453 78453-26 78453-TC 78454 78454-26 78454-TC 78456 78456-26 78456-TC 78457 78457-26 78457-TC 78458 78458-26 78458-TC 78459

$181.00 $42.00 $137.00 $205.00 $44.00 $159.00 $233.00 $52.00 $179.00 $276.00 $53.00 $220.00 $40.00 $11.00 $29.00 $23.00 BR BR BR BR $23.00 BR $126.00 $41.00 $84.00 $97.00 $28.00 $69.00 ------------------------------------------------------------------------------------------------$205.00 $49.00 $151.00 $140.00 $39.00 $99.00 $198.00 $46.00 $149.00 BR

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$257.00 $46.00 $211.00 $280.00 $48.00 $233.00 $385.00 $56.00 $329.00 $254.00 $56.00 $197.00 $36.00 $12.00 $24.00 $17.00 --------------------------------$25.00 --------$201.00 $42.00 $158.00 $194.00 $26.00 $168.00 $379.00 $75.00 $304.00 $525.00 $88.00 $437.00 $338.00 $55.00 $283.00 $485.00 $75.00 $411.00 $351.00 $54.00 $296.00 $210.00 $43.00 $166.00 $186.00 $43.00 $144.00 $1,433.00

$274.00 $48.00 $226.00 $299.00 $49.00 $250.00 $411.00 $58.00 $353.00 $270.00 $58.00 $212.00 $38.00 $13.00 $25.00 $18.00 --------------------------------$26.00 --------$214.00 $43.00 $170.00 $208.00 $27.00 $181.00 $404.00 $77.00 $327.00 $560.00 $91.00 $469.00 $361.00 $57.00 $304.00 $518.00 $77.00 $441.00 $374.00 $56.00 $318.00 $224.00 $45.00 $179.00 $198.00 $43.00 $155.00 $1,534.00

$277.00 $49.00 $228.00 $303.00 $51.00 $252.00 $415.00 $60.00 $355.00 $273.00 $60.00 $214.00 $39.00 $13.00 $26.00 $18.00 --------------------------------$26.00 --------$216.00 $44.00 $172.00 $210.00 $27.00 $182.00 $408.00 $79.00 $329.00 $566.00 $93.00 $473.00 $364.00 $59.00 $306.00 $523.00 $80.00 $444.00 $378.00 $57.00 $320.00 $228.00 $47.00 $180.00 $200.00 $44.00 $156.00 $1,540.00

$257.00 $46.00 $211.00 $280.00 $48.00 $233.00 $385.00 $56.00 $329.00 $254.00 $56.00 $197.00 $36.00 $12.00 $24.00 $17.00 --------------------------------$25.00 --------$201.00 $42.00 $158.00 $194.00 $26.00 $168.00 $379.00 $75.00 $304.00 $525.00 $88.00 $437.00 $338.00 $55.00 $283.00 $485.00 $75.00 $411.00 $351.00 $54.00 $296.00 $210.00 $43.00 $166.00 $186.00 $43.00 $144.00 $1,433.00



Locality 04


$274.00 $48.00 $226.00 $299.00 $49.00 $250.00 $411.00 $58.00 $353.00 $270.00 $58.00 $212.00 $38.00 $13.00 $25.00 $18.00 --------------------------------$26.00 --------$214.00 $43.00 $170.00 $208.00 $27.00 $181.00 $404.00 $77.00 $327.00 $560.00 $91.00 $469.00 $361.00 $57.00 $304.00 $518.00 $77.00 $441.00 $374.00 $56.00 $318.00 $224.00 $45.00 $179.00 $198.00 $43.00 $155.00 $1,534.00

$277.00 $49.00 $228.00 $303.00 $51.00 $252.00 $415.00 $60.00 $355.00 $273.00 $60.00 $214.00 $39.00 $13.00 $26.00 $18.00 --------------------------------$26.00 --------$216.00 $44.00 $172.00 $210.00 $27.00 $182.00 $408.00 $79.00 $329.00 $566.00 $93.00 $473.00 $364.00 $59.00 $306.00 $523.00 $80.00 $444.00 $378.00 $57.00 $320.00 $228.00 $47.00 $180.00 $200.00 $44.00 $156.00 $1,540.00

Part C, 311


Radiology CPT Code

2003 MRA


$100.00 BR $135.00 $36.00 $97.00 $180.00 $41.00 $137.00 $244.00 $47.00 $195.00 $259.00 $50.00 $206.00 $387.00 $75.00 $308.00 $248.00 $51.00 $195.00 $373.00 $77.00 $294.00 BR $85.00 BR BR $100.00 BR $324.00 $59.00 $262.00 $92.00 $24.00 $66.00 BR BR BR ------------------------$167.00 $38.00 $128.00 -------------------------------------------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$79.00 $1,353.00 $212.00 $39.00 $173.00 $220.00 $44.00 $176.00 $252.00 $51.00 $201.00 $255.00 $54.00 $202.00 $322.00 $80.00 $242.00 $194.00 $53.00 $141.00 $269.00 $80.00 $189.00 $1,433.00 $80.00 $1,353.00 $1,453.00 $100.00 $1,353.00 $250.00 $65.00 $185.00 $50.00 $27.00 $22.00 ------------------------$207.00 $26.00 $181.00 $266.00 $41.00 $225.00 $372.00 $59.00 $313.00 $225.00 $40.00 $185.00

$81.00 $1,452.00 $226.00 $40.00 $186.00 $234.00 $45.00 $189.00 $268.00 $52.00 $216.00 $272.00 $55.00 $217.00 $342.00 $82.00 $260.00 $206.00 $55.00 $151.00 $285.00 $82.00 $204.00 $1,534.00 $82.00 $1,452.00 $1,555.00 $103.00 $1,452.00 $266.00 $67.00 $199.00 $52.00 $28.00 $24.00 ------------------------$221.00 $27.00 $194.00 $284.00 $42.00 $242.00 $398.00 $61.00 $337.00 $240.00 $41.00 $199.00

$83.00 $1,457.00 $228.00 $41.00 $187.00 $237.00 $46.00 $191.00 $271.00 $54.00 $217.00 $275.00 $57.00 $218.00 $346.00 $84.00 $262.00 $208.00 $56.00 $152.00 $289.00 $84.00 $205.00 $1,541.00 $84.00 $1,457.00 $1,562.00 $105.00 $1,457.00 $269.00 $68.00 $201.00 $53.00 $29.00 $25.00 ------------------------$224.00 $28.00 $196.00 $287.00 $44.00 $243.00 $402.00 $63.00 $339.00 $242.00 $42.00 $200.00

$79.00 $1,353.00 $212.00 $39.00 $173.00 $220.00 $44.00 $176.00 $252.00 $51.00 $201.00 $255.00 $54.00 $202.00 $322.00 $80.00 $242.00 $194.00 $53.00 $141.00 $269.00 $80.00 $189.00 $1,433.00 $80.00 $1,353.00 $1,453.00 $100.00 $1,353.00 $250.00 $65.00 $185.00 $50.00 $27.00 $22.00 ------------------------$207.00 $26.00 $181.00 $266.00 $41.00 $225.00 $372.00 $59.00 $313.00 $225.00 $40.00 $185.00



Locality 04


$81.00 $1,452.00 $226.00 $40.00 $186.00 $234.00 $45.00 $189.00 $268.00 $52.00 $216.00 $272.00 $55.00 $217.00 $342.00 $82.00 $260.00 $206.00 $55.00 $151.00 $285.00 $82.00 $204.00 $1,534.00 $82.00 $1,452.00 $1,555.00 $103.00 $1,452.00 $266.00 $67.00 $199.00 $52.00 $28.00 $24.00 ------------------------$221.00 $27.00 $194.00 $284.00 $42.00 $242.00 $398.00 $61.00 $337.00 $240.00 $41.00 $199.00

$83.00 $1,457.00 $228.00 $41.00 $187.00 $237.00 $46.00 $191.00 $271.00 $54.00 $217.00 $275.00 $57.00 $218.00 $346.00 $84.00 $262.00 $208.00 $56.00 $152.00 $289.00 $84.00 $205.00 $1,541.00 $84.00 $1,457.00 $1,562.00 $105.00 $1,457.00 $269.00 $68.00 $201.00 $53.00 $29.00 $25.00 ------------------------$224.00 $28.00 $196.00 $287.00 $44.00 $243.00 $402.00 $63.00 $339.00 $242.00 $42.00 $200.00

Part C, 312


Radiology CPT Code

2003 MRA


------------------------BR BR BR $131.00 $22.00 $108.00 $154.00 $26.00 $126.00 $155.00 $27.00 $126.00 $221.00 $45.00 $177.00 $311.00 $64.00 $245.00 BR ----------------BR ----------------$74.00 $15.00 $59.00 $223.00 $35.00 $188.00 $129.00 $32.00 $95.00 $158.00 $29.00 $128.00 $268.00 $46.00 $220.00 $206.00 $31.00 $173.00 $107.00 $27.00 $79.00 BR BR

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$341.00 $47.00 $294.00 ------------------------$206.00 $25.00 $180.00 $237.00 $28.00 $209.00 $221.00 $30.00 $191.00 $367.00 $35.00 $332.00 $390.00 $66.00 $323.00 $1,434.00 $80.00 $1,353.00 $83.00 $83.00 BR $194.00 $17.00 $177.00 $375.00 $38.00 $337.00 $375.00 $34.00 $341.00 $358.00 $31.00 $326.00 $388.00 $51.00 $338.00 $365.00 $34.00 $331.00 $200.00 $30.00 $170.00 -----------------

$364.00 $48.00 $316.00 ------------------------$220.00 $26.00 $194.00 $254.00 $29.00 $225.00 $236.00 $31.00 $205.00 $393.00 $36.00 $356.00 $416.00 $68.00 $348.00 $1,535.00 $83.00 $1,452.00 $85.00 $85.00 BR $208.00 $18.00 $190.00 $402.00 $39.00 $363.00 $402.00 $35.00 $367.00 $383.00 $32.00 $351.00 $415.00 $52.00 $363.00 $391.00 $35.00 $356.00 $214.00 $31.00 $183.00 -----------------

$368.00 $49.00 $318.00 ------------------------$223.00 $27.00 $195.00 $256.00 $30.00 $226.00 $239.00 $32.00 $207.00 $396.00 $37.00 $359.00 $420.00 $70.00 $350.00 $1,542.00 $85.00 $1,457.00 $86.00 $86.00 BR $210.00 $18.00 $192.00 $405.00 $40.00 $365.00 $405.00 $36.00 $369.00 $386.00 $33.00 $353.00 $419.00 $54.00 $365.00 $394.00 $36.00 $358.00 $216.00 $32.00 $184.00 -----------------

$341.00 $47.00 $294.00 ------------------------$206.00 $25.00 $180.00 $237.00 $28.00 $209.00 $221.00 $30.00 $191.00 $367.00 $35.00 $332.00 $390.00 $66.00 $323.00 $1,434.00 $80.00 $1,353.00 $83.00 $83.00 BR $194.00 $17.00 $177.00 $375.00 $38.00 $337.00 $375.00 $34.00 $341.00 $358.00 $31.00 $326.00 $388.00 $51.00 $338.00 $365.00 $34.00 $331.00 $200.00 $30.00 $170.00 -----------------



Locality 04


$364.00 $48.00 $316.00 ------------------------$220.00 $26.00 $194.00 $254.00 $29.00 $225.00 $236.00 $31.00 $205.00 $393.00 $36.00 $356.00 $416.00 $68.00 $348.00 $1,535.00 $83.00 $1,452.00 $85.00 $85.00 BR $208.00 $18.00 $190.00 $402.00 $39.00 $363.00 $402.00 $35.00 $367.00 $383.00 $32.00 $351.00 $415.00 $52.00 $363.00 $391.00 $35.00 $356.00 $214.00 $31.00 $183.00 -----------------

$368.00 $49.00 $318.00 ------------------------$223.00 $27.00 $195.00 $256.00 $30.00 $226.00 $239.00 $32.00 $207.00 $396.00 $37.00 $359.00 $420.00 $70.00 $350.00 $1,542.00 $85.00 $1,457.00 $86.00 $86.00 BR $210.00 $18.00 $192.00 $405.00 $40.00 $365.00 $405.00 $36.00 $369.00 $386.00 $33.00 $353.00 $419.00 $54.00 $365.00 $394.00 $36.00 $358.00 $216.00 $32.00 $184.00 -----------------

Part C, 313


Radiology CPT Code

2003 MRA


BR $137.00 $22.00 $113.00 $158.00 $24.00 $133.00 $217.00 $49.00 $166.00 $231.00 $61.00 $166.00 $241.00 $68.00 $166.00 $256.00 $34.00 $220.00 $87.00 $19.00 $66.00 $73.00 $18.00 $55.00 $109.00 $29.00 $79.00 $157.00 $36.00 $119.00 BR BR BR $162.00 $34.00 $126.00 $199.00 $40.00 $158.00 $252.00 $44.00 $207.00 $303.00 $56.00 $245.00 ------------------------$166.00

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

--------$191.00 $25.00 $166.00 $234.00 $26.00 $207.00 $259.00 $52.00 $206.00 $195.00 $66.00 $128.00 $404.00 $77.00 $327.00 $222.00 $34.00 $188.00 $121.00 $21.00 $100.00 $84.00 $9.00 $76.00 $242.00 $31.00 $211.00 $232.00 $40.00 $192.00 ------------------------$213.00 $38.00 $175.00 $290.00 $45.00 $245.00 $361.00 $47.00 $314.00 $378.00 $58.00 $319.00 $628.00 $58.00 $570.00 $203.00

--------$204.00 $26.00 $178.00 $250.00 $27.00 $223.00 $276.00 $54.00 $221.00 $207.00 $68.00 $138.00 $431.00 $79.00 $352.00 $237.00 $35.00 $202.00 $129.00 $21.00 $108.00 $90.00 $9.00 $81.00 $258.00 $32.00 $227.00 $248.00 $42.00 $206.00 ------------------------$228.00 $40.00 $188.00 $310.00 $47.00 $263.00 $385.00 $48.00 $337.00 $403.00 $60.00 $343.00 $673.00 $60.00 $612.00 $216.00

--------$206.00 $26.00 $180.00 $252.00 $28.00 $224.00 $279.00 $56.00 $223.00 $210.00 $70.00 $140.00 $435.00 $82.00 $354.00 $240.00 $36.00 $204.00 $131.00 $22.00 $109.00 $91.00 $9.00 $82.00 $260.00 $32.00 $228.00 $250.00 $43.00 $208.00 ------------------------$231.00 $42.00 $189.00 $314.00 $49.00 $265.00 $389.00 $50.00 $339.00 $407.00 $62.00 $345.00 $678.00 $62.00 $616.00 $219.00

--------$191.00 $25.00 $166.00 $234.00 $26.00 $207.00 $259.00 $52.00 $206.00 $195.00 $66.00 $128.00 $404.00 $77.00 $327.00 $222.00 $34.00 $188.00 $121.00 $21.00 $100.00 $84.00 $9.00 $76.00 $242.00 $31.00 $211.00 $232.00 $40.00 $192.00 ------------------------$213.00 $38.00 $175.00 $290.00 $45.00 $245.00 $361.00 $47.00 $314.00 $378.00 $58.00 $319.00 $628.00 $58.00 $570.00 $203.00



Locality 04


--------$204.00 $26.00 $178.00 $250.00 $27.00 $223.00 $276.00 $54.00 $221.00 $207.00 $68.00 $138.00 $431.00 $79.00 $352.00 $237.00 $35.00 $202.00 $129.00 $21.00 $108.00 $90.00 $9.00 $81.00 $258.00 $32.00 $227.00 $248.00 $42.00 $206.00 ------------------------$228.00 $40.00 $188.00 $310.00 $47.00 $263.00 $385.00 $48.00 $337.00 $403.00 $60.00 $343.00 $673.00 $60.00 $612.00 $216.00

--------$206.00 $26.00 $180.00 $252.00 $28.00 $224.00 $279.00 $56.00 $223.00 $210.00 $70.00 $140.00 $435.00 $82.00 $354.00 $240.00 $36.00 $204.00 $131.00 $22.00 $109.00 $91.00 $9.00 $82.00 $260.00 $32.00 $228.00 $250.00 $43.00 $208.00 ------------------------$231.00 $42.00 $189.00 $314.00 $49.00 $265.00 $389.00 $50.00 $339.00 $407.00 $62.00 $345.00 $678.00 $62.00 $616.00 $219.00

Part C, 314


Radiology CPT Code

2003 MRA

78805-26 78805-TC 78806 78806-26 78806-TC 78807 78807-26 78807-TC 78808 78811 78811-26 78811-TC 78812 78812-26 78812-TC 78813 78813-26 78813-TC 78814 78814-26 78814-TC 78815 78815-26 78815-TC 78816 78816-26 78816-TC 78999 78999-26 78999-TC 79005 79005-26 79005-TC 79101 79101-26 79101-TC 79200 79200-26 79200-TC 79300 79300-26 79300-TC 79403 79403-26 79403-TC 79440 79440-26 79440-TC 79445 79445-26

$38.00 $126.00 $286.00 $44.00 $241.00 $303.00 $57.00 $245.00 --------------------------------------------------------------------------------------------------------------------------------------------------------BR BR BR ------------------------------------------------$203.00 $102.00 $97.00 BR $83.00 BR ------------------------$204.00 $104.00 $97.00 -----------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$40.00 $163.00 $370.00 $47.00 $323.00 $378.00 $58.00 $320.00 $50.00 $1,440.00 $87.00 $1,353.00 $1,459.00 $105.00 $1,353.00 $1,463.00 $110.00 $1,353.00 $1,475.00 $121.00 $1,353.00 $1,487.00 $134.00 $1,353.00 $1,489.00 $135.00 $1,353.00 ------------------------$151.00 $98.00 $53.00 $158.00 $107.00 $51.00 $176.00 $114.00 $63.00 --------$89.00 --------$213.00 $124.00 $89.00 $160.00 $106.00 $54.00 BR $129.00

$42.00 $175.00 $395.00 $48.00 $347.00 $403.00 $60.00 $343.00 $54.00 $1,542.00 $90.00 $1,452.00 $1,561.00 $108.00 $1,452.00 $1,566.00 $114.00 $1,452.00 $1,577.00 $125.00 $1,452.00 $1,590.00 $138.00 $1,452.00 $1,592.00 $139.00 $1,452.00 ------------------------$158.00 $101.00 $57.00 $165.00 $110.00 $55.00 $185.00 $117.00 $67.00 --------$91.00 --------$223.00 $128.00 $95.00 $167.00 $109.00 $58.00 BR $133.00

$43.00 $176.00 $399.00 $50.00 $349.00 $407.00 $61.00 $346.00 $55.00 $1,549.00 $93.00 $1,457.00 $1,568.00 $111.00 $1,457.00 $1,573.00 $117.00 $1,457.00 $1,585.00 $129.00 $1,457.00 $1,599.00 $142.00 $1,457.00 $1,600.00 $143.00 $1,457.00 ------------------------$162.00 $104.00 $58.00 $168.00 $112.00 $55.00 $188.00 $120.00 $68.00 --------$93.00 --------$227.00 $131.00 $97.00 $170.00 $111.00 $58.00 BR $137.00

$40.00 $163.00 $370.00 $47.00 $323.00 $378.00 $58.00 $320.00 $50.00 $1,440.00 $87.00 $1,353.00 $1,459.00 $105.00 $1,353.00 $1,463.00 $110.00 $1,353.00 $1,475.00 $121.00 $1,353.00 $1,487.00 $134.00 $1,353.00 $1,489.00 $135.00 $1,353.00 ------------------------$151.00 $98.00 $53.00 $158.00 $107.00 $51.00 $176.00 $114.00 $63.00 --------$89.00 --------$213.00 $124.00 $89.00 $160.00 $106.00 $54.00 BR $129.00



Locality 04


$42.00 $175.00 $395.00 $48.00 $347.00 $403.00 $60.00 $343.00 $54.00 $1,542.00 $90.00 $1,452.00 $1,561.00 $108.00 $1,452.00 $1,566.00 $114.00 $1,452.00 $1,577.00 $125.00 $1,452.00 $1,590.00 $138.00 $1,452.00 $1,592.00 $139.00 $1,452.00 ------------------------$158.00 $101.00 $57.00 $165.00 $110.00 $55.00 $185.00 $117.00 $67.00 --------$91.00 --------$223.00 $128.00 $95.00 $167.00 $109.00 $58.00 BR $133.00

$43.00 $176.00 $399.00 $50.00 $349.00 $407.00 $61.00 $346.00 $55.00 $1,549.00 $93.00 $1,457.00 $1,568.00 $111.00 $1,457.00 $1,573.00 $117.00 $1,457.00 $1,585.00 $129.00 $1,457.00 $1,599.00 $142.00 $1,457.00 $1,600.00 $143.00 $1,457.00 ------------------------$162.00 $104.00 $58.00 $168.00 $112.00 $55.00 $188.00 $120.00 $68.00 --------$93.00 --------$227.00 $131.00 $97.00 $170.00 $111.00 $58.00 BR $137.00

Part C, 315


Radiology CPT Code

2003 MRA

79445-TC 79999 79999-26 79999-TC G0130 G0130-26 G0130-TC G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0252-26 G0278 G0279 G0279-26 G0279-TC G0288 G0297 G0297-26 G0297-TC G0365 G0365-26 G0365-TC G0389 G0389-26 G0389-TC G6001 G6001-26 G6001-TC G6002 G6002-26 G6002-TC G6003 G6004 G6005 G6006 G6007 G6008 G6009 G6010 G6011 G6012 G6013 G6014 G6015

--------BR BR BR ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

BR ------------------------$37.00 $13.00 $24.00 $144.00 $39.00 $105.00 $177.00 $49.00 $128.00 $139.00 $39.00 $100.00 $83.00 $16.00 $60.00 $34.00 $27.00 $40.00 $271.00 $56.00 $215.00 $176.00 $14.00 $162.00 $125.00 $33.00 $92.00 $57.00 $33.00 $24.00 $81.00 $22.00 $59.00 $199.00 $154.00 $154.00 $153.00 $320.00 $213.00 $211.00 $210.00 $342.00 $281.00 $281.00 $281.00 $367.00

BR ------------------------$39.00 $13.00 $26.00 $153.00 $40.00 $113.00 $188.00 $51.00 $137.00 $147.00 $40.00 $107.00 $85.00 $18.00 $63.00 $35.00 $29.00 $44.00 $289.00 $58.00 $231.00 $189.00 $15.00 $174.00 $133.00 $34.00 $99.00 $59.00 $34.00 $25.00 $86.00 $23.00 $63.00 $214.00 $165.00 $165.00 $165.00 $343.00 $229.00 $226.00 $226.00 $367.00 $301.00 $302.00 $302.00 $395.00

BR ------------------------$40.00 $13.00 $27.00 $155.00 $42.00 $114.00 $190.00 $52.00 $138.00 $149.00 $42.00 $108.00 $86.00 $19.00 $64.00 $36.00 $29.00 $47.00 $291.00 $59.00 $232.00 $191.00 $16.00 $175.00 $135.00 $35.00 $100.00 $60.00 $35.00 $26.00 $87.00 $24.00 $64.00 $215.00 $166.00 $166.00 $165.00 $345.00 $230.00 $227.00 $227.00 $368.00 $302.00 $303.00 $303.00 $397.00

BR ------------------------$37.00 $13.00 $24.00 $144.00 $39.00 $105.00 $177.00 $49.00 $128.00 $139.00 $39.00 $100.00 $83.00 $16.00 $60.00 $34.00 $27.00 $40.00 $271.00 $56.00 $215.00 $176.00 $14.00 $162.00 $125.00 $33.00 $92.00 $57.00 $33.00 $24.00 $81.00 $22.00 $59.00 $199.00 $154.00 $154.00 $153.00 $320.00 $213.00 $211.00 $210.00 $342.00 $281.00 $281.00 $281.00 $367.00



Locality 04


BR ------------------------$39.00 $13.00 $26.00 $153.00 $40.00 $113.00 $188.00 $51.00 $137.00 $147.00 $40.00 $107.00 $85.00 $18.00 $63.00 $35.00 $29.00 $44.00 $289.00 $58.00 $231.00 $189.00 $15.00 $174.00 $133.00 $34.00 $99.00 $59.00 $34.00 $25.00 $86.00 $23.00 $63.00 $214.00 $165.00 $165.00 $165.00 $343.00 $229.00 $226.00 $226.00 $367.00 $301.00 $302.00 $302.00 $395.00

BR ------------------------$40.00 $13.00 $27.00 $155.00 $42.00 $114.00 $190.00 $52.00 $138.00 $149.00 $42.00 $108.00 $86.00 $19.00 $64.00 $36.00 $29.00 $47.00 $291.00 $59.00 $232.00 $191.00 $16.00 $175.00 $135.00 $35.00 $100.00 $60.00 $35.00 $26.00 $87.00 $24.00 $64.00 $215.00 $166.00 $166.00 $165.00 $345.00 $230.00 $227.00 $227.00 $368.00 $302.00 $303.00 $303.00 $397.00

Part C, 316


Radiology CPT Code G6016 Q0092

2003 MRA -----------------

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$366.00 $27.00

$393.00 $29.00

$394.00 $29.00

$366.00 $27.00



Locality 04


$393.00 $29.00

$394.00 $29.00

Part C, 317

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2016 Edition Pathology & Laboratory CPT Code

2003 MRA


$23.00 $4.00 $19.00 $45.00 $18.00 $26.00 $16.00 $6.00 $10.00 $29.00 $8.00 $21.00 $67.00 $21.00 $43.00 $31.00 $11.00 $19.00 $26.00 $6.00 $20.00 $107.00 $43.00 $64.00 $18.00 $7.00 $11.00 $40.00 $13.00 $26.00 $35.00 $11.00 $23.00 $22.00 $8.00 $14.00 $35.00 $12.00 $22.00 $13.00 $3.00 $9.00 $43.00 $14.00 $29.00 $43.00 $17.00 $25.00 $18.00 $6.00

RULE- 69L-7.020, F.A.C., Effective July 1, 2017

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 318


2003 MRA


$11.00 $33.00 $11.00 $22.00 $35.00 $11.00 $23.00 $17.00 $6.00 $11.00 $34.00 $10.00 $23.00 $36.00 $10.00 $25.00 $38.00 $11.00 $26.00 $35.00 $11.00 $23.00 $41.00 $13.00 $28.00 $44.00 $17.00 $26.00 $33.00 $10.00 $22.00 $34.00 $11.00 $22.00 $20.00 $5.00 $15.00 $24.00 $7.00 $16.00 $33.00 $11.00 $21.00 $42.00 $14.00 $28.00 BR BR BR $54.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 319


2003 MRA


$18.00 $36.00 $138.00 $42.00 $95.00 $138.00 $42.00 $95.00 $213.00 $77.00 $136.00 $166.00 $54.00 $110.00 $533.00 $176.00 $355.00 $88.00 $26.00 $59.00 $93.00 $28.00 $64.00 $256.00 $88.00 $166.00 $256.00 $88.00 $166.00 $934.00 $266.00 $666.00 $107.00 $33.00 $74.00 $62.00 $18.00 $43.00 $94.00 $26.00 $67.00 $232.00 $54.00 $176.00 $93.00 $19.00 $73.00 $99.00 $24.00 $74.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 320


2003 MRA


$243.00 $56.00 $186.00 $161.00 $49.00 $110.00 $166.00 $49.00 $115.00 $119.00 $35.00 $85.00 $82.00 $24.00 $56.00 $176.00 $33.00 $144.00 $34.00 $34.00 BR $72.00 $72.00 BR $7.00 $3.00 $4.00 $7.00 $3.00 $4.00 $5.00 $3.00 $3.00 $5.00 $2.00 $3.00 $3.00 $1.00 $3.00 $5.00 $2.00 $4.00 $5.00 $3.00 $3.00 $8.00 $3.00 $5.00 $7.00 $4.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------------------------------------------------------$24.00 ----------------$79.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------$25.00 ----------------$82.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------$26.00 ----------------$84.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------$22.00 ----------------$77.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------------------------------------------------------------------------------$22.00 ----------------$79.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------$23.00 ----------------$81.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 321


2003 MRA


$4.00 $33.00 $11.00 $21.00 BR BR BR $10.00 $3.00 $6.00 $22.00 $7.00 $15.00 $24.00 $7.00 $17.00 $26.00 $7.00 $18.00 $43.00 $17.00 $25.00 $11.00 $3.00 $7.00 $12.00 $3.00 $8.00 $14.00 $4.00 $10.00 $12.00 $4.00 $9.00 $32.00 $10.00 $21.00 $24.00 $7.00 $17.00 $91.00 $28.00 $62.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $26.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 322


2003 MRA


$8.00 $18.00 $26.00 $8.00 $18.00 $45.00 $14.00 $32.00 $9.00 $3.00 $5.00 $33.00 $11.00 $22.00 $26.00 $6.00 $19.00 $57.00 $13.00 $44.00 $41.00 $13.00 $28.00 $38.00 $14.00 $23.00 $38.00 $14.00 $23.00 $40.00 $12.00 $28.00 $28.00 $8.00 $19.00 $16.00 $5.00 $11.00 $34.00 $13.00 $20.00 $57.00 $17.00 $40.00 $67.00 $21.00 $43.00 $42.00 $12.00 $31.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 323


2003 MRA


$32.00 $10.00 $21.00 $33.00 $10.00 $22.00 $48.00 $15.00 $33.00 $25.00 $8.00 $17.00 $24.00 $8.00 $16.00 $43.00 $14.00 $29.00 $23.00 $8.00 $15.00 $49.00 $15.00 $34.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $11.00 $3.00 $7.00 $38.00 $13.00 $24.00 $5.00 $2.00 $3.00 BR BR BR $12.00 $3.00 $8.00 $48.00 $15.00 $33.00 $79.00 $25.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 324


2003 MRA


$52.00 $62.00 $18.00 $43.00 $11.00 $3.00 $7.00 $37.00 $11.00 $25.00 $14.00 $4.00 $10.00 $13.00 $4.00 $8.00 $31.00 $10.00 $20.00 $31.00 $10.00 $20.00 $31.00 $8.00 $21.00 $22.00 $7.00 $15.00 $16.00 $5.00 $11.00 $10.00 $3.00 $6.00 $26.00 $7.00 $18.00 $11.00 $3.00 $7.00 $31.00 $8.00 $21.00 $38.00 $13.00 $24.00 $21.00 $6.00 $15.00 $38.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 325


2003 MRA


$12.00 $25.00 $62.00 $18.00 $43.00 $62.00 $18.00 $43.00 $34.00 $10.00 $23.00 $24.00 $7.00 $17.00 $22.00 $7.00 $15.00 $28.00 $8.00 $19.00 $8.00 $2.00 $6.00 $14.00 $4.00 $10.00 $13.00 $4.00 $8.00 $16.00 $5.00 $11.00 $8.00 $2.00 $6.00 $23.00 $6.00 $17.00 $23.00 $7.00 $15.00 $37.00 $8.00 $28.00 $48.00 $16.00 $32.00 $55.00 $16.00 $39.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 326


2003 MRA


$43.00 $17.00 $25.00 $34.00 $10.00 $23.00 $40.00 $13.00 $26.00 $38.00 $12.00 $25.00 $35.00 $10.00 $24.00 $10.00 $3.00 $6.00 $42.00 $13.00 $28.00 $16.00 $4.00 $12.00 $33.00 $10.00 $22.00 $16.00 $5.00 $11.00 $19.00 $6.00 $13.00 $13.00 $2.00 $11.00 $10.00 $2.00 $7.00 $25.00 $8.00 $17.00 $15.00 $3.00 $12.00 $31.00 $10.00 $21.00 $40.00 $12.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 327


2003 MRA


$28.00 $38.00 $10.00 $27.00 $40.00 $13.00 $26.00 $17.00 $5.00 $12.00 $59.00 $19.00 $40.00 $37.00 $12.00 $24.00 $81.00 $23.00 $56.00 $81.00 $23.00 $56.00 $23.00 $7.00 $16.00 $89.00 $25.00 $62.00 $42.00 $13.00 $28.00 $42.00 $13.00 $28.00 $40.00 $13.00 $26.00 $45.00 $14.00 $32.00 $61.00 $18.00 $42.00 $61.00 $17.00 $43.00 $57.00 $16.00 $41.00 $52.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 328


2003 MRA


$17.00 $35.00 $70.00 $20.00 $48.00 $23.00 $7.00 $16.00 $57.00 $19.00 $38.00 $14.00 $6.00 $9.00 $42.00 $13.00 $29.00 $33.00 $11.00 $21.00 $28.00 $8.00 $19.00 $42.00 $13.00 $28.00 $24.00 $7.00 $17.00 $36.00 $12.00 $23.00 $39.00 $13.00 $25.00 $29.00 $10.00 $19.00 $36.00 $11.00 $24.00 $38.00 $12.00 $25.00 $26.00 $8.00 $18.00 $47.00 $14.00 $33.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 329


2003 MRA


$14.00 $3.00 $11.00 $15.00 $5.00 $11.00 $33.00 $11.00 $21.00 $54.00 $17.00 $37.00 $22.00 $6.00 $16.00 $53.00 $16.00 $37.00 $36.00 $10.00 $24.00 $28.00 $8.00 $19.00 $16.00 $5.00 $11.00 $48.00 $16.00 $32.00 $47.00 $15.00 $32.00 $38.00 $12.00 $25.00 $9.00 $3.00 $5.00 $29.00 $7.00 $21.00 $11.00 $3.00 $7.00 $5.00 $3.00 $3.00 $12.00 $4.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 330


2003 MRA


$7.00 $22.00 $7.00 $15.00 $11.00 $3.00 $7.00 $25.00 $7.00 $18.00 $14.00 $4.00 $10.00 $5.00 $1.00 $4.00 $54.00 $17.00 $37.00 $16.00 $5.00 $11.00 $16.00 $4.00 $12.00 $25.00 $7.00 $18.00 $18.00 $5.00 $13.00 $41.00 $12.00 $29.00 $40.00 $12.00 $28.00 $42.00 $13.00 $29.00 $36.00 $10.00 $25.00 $26.00 $8.00 $18.00 $36.00 $14.00 $21.00 $133.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 331


2003 MRA


$38.00 $94.00 $19.00 $6.00 $13.00 $51.00 $15.00 $36.00 $56.00 $16.00 $40.00 $24.00 $6.00 $18.00 $39.00 $13.00 $25.00 $8.00 $5.00 $3.00 $18.00 $6.00 $12.00 $15.00 $4.00 $11.00 $15.00 $5.00 $10.00 $13.00 $4.00 $8.00 $16.00 $5.00 $11.00 $16.00 $5.00 $11.00 $22.00 $6.00 $16.00 $18.00 $6.00 $12.00 $20.00 $5.00 $15.00 $11.00 $3.00 $7.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 332


2003 MRA


$13.00 $4.00 $8.00 $38.00 $11.00 $26.00 $59.00 $18.00 $41.00 $38.00 $13.00 $25.00 $49.00 $16.00 $33.00 $37.00 $11.00 $25.00 $35.00 $11.00 $23.00 $62.00 $20.00 $41.00 $51.00 $15.00 $36.00 $69.00 $21.00 $45.00 $77.00 $21.00 $54.00 $26.00 $8.00 $18.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $31.00 $8.00 $21.00 $35.00 $11.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 333


2003 MRA


$23.00 $43.00 $14.00 $29.00 $16.00 $3.00 $13.00 $20.00 $5.00 $15.00 $23.00 $7.00 $16.00 $34.00 $8.00 $24.00 $38.00 $13.00 $24.00 $59.00 $18.00 $41.00 $19.00 $6.00 $13.00 $16.00 $5.00 $11.00 $23.00 $6.00 $17.00 $42.00 $14.00 $28.00 $31.00 $8.00 $21.00 $18.00 $5.00 $13.00 $18.00 $6.00 $12.00 $16.00 $5.00 $11.00 $42.00 $14.00 $28.00 $16.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 334


2003 MRA


$5.00 $11.00 $43.00 $14.00 $29.00 $15.00 $5.00 $10.00 $17.00 $5.00 $12.00 $58.00 $17.00 $41.00 $39.00 $13.00 $25.00 $34.00 $11.00 $22.00 $41.00 $12.00 $29.00 $26.00 $8.00 $18.00 $32.00 $8.00 $22.00 $13.00 $4.00 $8.00 $54.00 $18.00 $36.00 $25.00 $8.00 $17.00 BR BR BR $11.00 $3.00 $7.00 $45.00 $14.00 $32.00 $31.00 $10.00 $20.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 335


2003 MRA


$54.00 $18.00 $36.00 $41.00 $12.00 $29.00 $42.00 $12.00 $29.00 $37.00 $12.00 $25.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $29.00 $10.00 $19.00 $32.00 $11.00 $20.00 BR BR BR $94.00 $31.00 $62.00 $8.00 $3.00 $5.00 $40.00 $12.00 $28.00 $11.00 $3.00 $7.00 $12.00 $3.00 $8.00 $20.00 $6.00 $14.00 $14.00 $4.00 $10.00 $18.00 $6.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 336


2003 MRA


$12.00 $12.00 $3.00 $8.00 $19.00 $5.00 $14.00 $36.00 $11.00 $24.00 $45.00 $15.00 $31.00 $15.00 $5.00 $10.00 $25.00 $7.00 $18.00 $11.00 $3.00 $7.00 $11.00 $3.00 $7.00 $10.00 $2.00 $7.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $38.00 $11.00 $26.00 $71.00 $20.00 $49.00 $11.00 $3.00 $7.00 $11.00 $3.00 $7.00 $24.00 $7.00 $17.00 $57.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 337


2003 MRA


$19.00 $38.00 $56.00 $18.00 $38.00 $41.00 $8.00 $33.00 $62.00 $20.00 $41.00 $38.00 $7.00 $31.00 $53.00 $17.00 $36.00 $69.00 $20.00 $47.00 $42.00 $14.00 $27.00 $33.00 $11.00 $21.00 $33.00 $11.00 $21.00 $12.00 $4.00 $7.00 $5.00 $2.00 $2.00 $24.00 $8.00 $16.00 ------------------------$29.00 $10.00 $19.00 $33.00 $11.00 $21.00 $39.00 $13.00 $25.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 --------BR $20.00 BR --------$20.00 ----------------$20.00 ---------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR --------$21.00 ----------------$21.00 ---------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR --------$21.00 ----------------$21.00 ---------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 --------BR $20.00 BR --------$20.00 ----------------$20.00 ---------------------------------



Locality 04


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR --------$21.00 ----------------$21.00 ---------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR --------$21.00 ----------------$21.00 ---------------------------------

Part C, 338


2003 MRA


$16.00 $5.00 $11.00 $32.00 $10.00 $21.00 $54.00 $16.00 $38.00 $24.00 $10.00 $15.00 $25.00 $8.00 $17.00 $32.00 $10.00 $21.00 $116.00 $35.00 $81.00 $116.00 $35.00 $81.00 $114.00 $34.00 $80.00 $97.00 $32.00 $65.00 $47.00 $15.00 $32.00 $47.00 $14.00 $33.00 $58.00 $17.00 $41.00 $54.00 $16.00 $38.00 $36.00 $11.00 $24.00 $37.00 $11.00 $25.00 $59.00 $17.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 339


2003 MRA


$42.00 $10.00 $3.00 $6.00 $10.00 $3.00 $6.00 BR BR BR $34.00 $11.00 $22.00 $26.00 $8.00 $18.00 $11.00 $3.00 $7.00 $5.00 $2.00 $3.00 $37.00 $11.00 $25.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $25.00 $8.00 $17.00 $25.00 $8.00 $17.00 $8.00 $2.00 $6.00 $72.00 $21.00 $49.00 $67.00 $19.00 $45.00 $54.00 $17.00 $37.00 $31.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 340


2003 MRA


$10.00 $20.00 $28.00 $8.00 $19.00 $14.00 $3.00 $11.00 $13.00 $4.00 $8.00 $16.00 $4.00 $12.00 $25.00 $6.00 $19.00 $32.00 $7.00 $23.00 $98.00 $29.00 $69.00 $35.00 $11.00 $23.00 $38.00 $13.00 $24.00 $11.00 $3.00 $7.00 $13.00 $4.00 $8.00 $22.00 $7.00 $15.00 $12.00 $3.00 $8.00 $15.00 $5.00 $10.00 $20.00 $6.00 $14.00 $33.00 $10.00 $22.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 341


2003 MRA


$45.00 $15.00 $31.00 $21.00 $6.00 $15.00 $15.00 $4.00 $11.00 $15.00 $4.00 $11.00 $15.00 $4.00 $11.00 $26.00 $8.00 $18.00 $17.00 $5.00 $12.00 $12.00 $3.00 $8.00 $7.00 $2.00 $5.00 $13.00 $4.00 $8.00 $18.00 $5.00 $13.00 $12.00 $4.00 $7.00 $12.00 $3.00 $8.00 $34.00 $11.00 $22.00 $7.00 $2.00 $5.00 $17.00 $5.00 $12.00 $11.00 $3.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 342


2003 MRA


$7.00 $36.00 $11.00 $24.00 $42.00 $14.00 $27.00 $73.00 $23.00 $47.00 $33.00 $11.00 $21.00 $26.00 $9.00 $18.00 $37.00 $11.00 $25.00 $43.00 $13.00 $31.00 $29.00 $8.00 $20.00 $26.00 $8.00 $18.00 $52.00 $17.00 $35.00 $38.00 $11.00 $26.00 $22.00 $6.00 $15.00 $17.00 $5.00 $12.00 BR BR BR $10.00 $3.00 $6.00 BR BR BR $6.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 343


2003 MRA


$3.00 $4.00 $5.00 $2.00 $3.00 $8.00 $3.00 $5.00 $3.00 $1.00 $2.00 $4.00 $1.00 $3.00 $5.00 $2.00 $3.00 $20.00 $6.00 $14.00 $15.00 $5.00 $10.00 BR BR BR $7.00 $3.00 $4.00 $10.00 $3.00 $6.00 $6.00 $2.00 $4.00 $13.00 $4.00 $9.00 $7.00 $3.00 $4.00 BR BR BR $25.00 $7.00 $18.00 $59.00 $59.00 BR


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$28.00 ----------------$98.00 -----------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00 ----------------$103.00 -----------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00 ----------------$105.00 -----------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$28.00 ----------------$56.00 -----------------



Locality 04


----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00 ----------------$58.00 -----------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00 ----------------$59.00 -----------------

Part C, 344


2003 MRA


$19.00 $6.00 $13.00 $7.00 $2.00 $5.00 $10.00 $3.00 $6.00 $31.00 $8.00 $21.00 $47.00 $15.00 $32.00 $47.00 $14.00 $33.00 $48.00 $15.00 $33.00 $49.00 $15.00 $34.00 $54.00 $18.00 $36.00 $54.00 $18.00 $36.00 $54.00 $18.00 $36.00 $49.00 $14.00 $35.00 $49.00 $14.00 $35.00 $49.00 $14.00 $35.00 $49.00 $14.00 $35.00 $44.00 $13.00 $32.00 $20.00 $6.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 345


2003 MRA


$14.00 $51.00 $17.00 $34.00 $51.00 $17.00 $34.00 $35.00 $12.00 $23.00 $29.00 $10.00 $19.00 $33.00 $11.00 $21.00 $26.00 $8.00 $18.00 $21.00 $7.00 $14.00 $29.00 $10.00 $19.00 $35.00 $12.00 $23.00 $21.00 $7.00 $14.00 $19.00 $6.00 $13.00 $10.00 $2.00 $7.00 $8.00 $2.00 $6.00 $10.00 $3.00 $6.00 $16.00 $4.00 $12.00 $18.00 $7.00 $11.00 $13.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 346


2003 MRA

85366-26 85366-TC 85370 85370-26 85370-TC 85378 85378-26 85378-TC 85379 85379-26 85379-TC 85380 85380-26 85380-TC 85384 85384-26 85384-TC 85385 85385-26 85385-TC 85390 85390-26 85390-TC 85396 85400 85400-26 85400-TC 85410 85410-26 85410-TC 85415 85415-26 85415-TC 85420 85420-26 85420-TC 85421 85421-26 85421-TC 85441 85441-26 85441-TC 85445 85445-26 85445-TC 85460 85460-26 85460-TC 85461 85461-26

$3.00 $10.00 $20.00 $5.00 $15.00 $13.00 $4.00 $8.00 $18.00 $6.00 $12.00 BR BR BR $11.00 $3.00 $7.00 $16.00 $5.00 $11.00 $10.00 $2.00 $7.00 --------$12.00 $3.00 $8.00 $12.00 $3.00 $8.00 $28.00 $10.00 $18.00 $16.00 $3.00 $13.00 $39.00 $12.00 $26.00 $7.00 $2.00 $5.00 $16.00 $5.00 $11.00 $15.00 $4.00 $11.00 $12.00 $3.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 --------$23.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------$24.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------$25.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 --------$23.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------$24.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 --------$25.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 347


2003 MRA


$8.00 $15.00 $4.00 $11.00 $22.00 $6.00 $16.00 $20.00 $6.00 $14.00 $39.00 $12.00 $26.00 $14.00 $4.00 $10.00 $24.00 $7.00 $17.00 $23.00 $6.00 $17.00 $45.00 $15.00 $31.00 $17.00 $5.00 $12.00 $34.00 $10.00 $23.00 $21.00 $5.00 $16.00 $32.00 $10.00 $21.00 $6.00 $3.00 $4.00 $6.00 $2.00 $4.00 $22.00 $6.00 $16.00 $15.00 $4.00 $11.00 $26.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 -----------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 -----------------------------------------------------------------------------------------------------------------------------------------



Locality 04


----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------

Part C, 348


2003 MRA


$8.00 $18.00 $8.00 $2.00 $6.00 $8.00 $2.00 $6.00 $10.00 $3.00 $6.00 $13.00 $3.00 $10.00 $13.00 $4.00 $8.00 $13.00 $4.00 $8.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $19.00 $4.00 $15.00 BR BR BR $16.00 $5.00 $11.00 $12.00 $4.00 $8.00 $6.00 $2.00 $3.00 $11.00 $4.00 $6.00 $41.00 $12.00 $29.00 $57.00 $18.00 $39.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 349


2003 MRA

86023 86023-26 86023-TC 86038 86038-26 86038-TC 86039 86039-26 86039-TC 86060 86060-26 86060-TC 86063 86063-26 86063-TC 86077 86077-26 86077-TC 86078 86078-26 86078-TC 86079 86079-26 86079-TC 86140 86140-26 86140-TC 86141 86141-26 86141-TC 86146 86146-26 86146-TC 86147 86147-26 86147-TC 86148 86148-26 86148-TC 86153-26 86155 86155-26 86155-TC 86156 86156-26 86156-TC 86157 86157-26 86157-TC 86160

$28.00 $10.00 $18.00 $22.00 $7.00 $15.00 $19.00 $6.00 $13.00 $13.00 $3.00 $10.00 $21.00 $6.00 $15.00 $91.00 $26.00 $64.00 $91.00 $26.00 $64.00 $79.00 $25.00 $52.00 $14.00 $4.00 $10.00 BR BR BR $58.00 $19.00 $39.00 $53.00 $16.00 $36.00 $59.00 $21.00 $38.00 --------$26.00 $8.00 $18.00 $11.00 $3.00 $7.00 $13.00 $4.00 $8.00 $21.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------------------------------$63.00 ----------------$62.00 ----------------$62.00 ----------------------------------------------------------------------------------------------------------------------------------------$38.00 ---------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------$65.00 ----------------$65.00 ----------------$64.00 ----------------------------------------------------------------------------------------------------------------------------------------$39.00 ---------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------$67.00 ----------------$66.00 ----------------$66.00 ----------------------------------------------------------------------------------------------------------------------------------------$40.00 ---------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------$58.00 ----------------$58.00 ----------------$57.00 ----------------------------------------------------------------------------------------------------------------------------------------$38.00 ---------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------------------------------------------------------$60.00 ----------------$60.00 ----------------$59.00 ----------------------------------------------------------------------------------------------------------------------------------------$39.00 ---------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------$62.00 ----------------$62.00 ----------------$61.00 ----------------------------------------------------------------------------------------------------------------------------------------$40.00 ---------------------------------------------------------------------------------

Part C, 350


2003 MRA


$5.00 $16.00 $21.00 $5.00 $16.00 $54.00 $18.00 $36.00 $25.00 $7.00 $18.00 $19.00 $6.00 $13.00 $36.00 $12.00 $23.00 $36.00 $11.00 $24.00 $24.00 $8.00 $16.00 $33.00 $10.00 $22.00 $50.00 $15.00 $35.00 $25.00 $8.00 $17.00 $25.00 $8.00 $17.00 $41.00 $14.00 $26.00 $15.00 $3.00 $12.00 BR BR BR $47.00 $15.00 $32.00 $47.00 $15.00 $32.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ----------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ----------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------

Part C, 351


2003 MRA


$47.00 $15.00 $32.00 $8.00 $3.00 $5.00 $12.00 $3.00 $8.00 $19.00 $6.00 $13.00 $37.00 $11.00 $25.00 $31.00 $10.00 $20.00 $23.00 $10.00 $14.00 $49.00 $19.00 $29.00 $49.00 $16.00 $33.00 $62.00 $19.00 $42.00 $37.00 $12.00 $24.00 $22.00 $6.00 $15.00 $54.00 $18.00 $36.00 $65.00 $18.00 $45.00 ------------------------BR BR BR $54.00 $18.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ----------------$20.00 ----------------$23.00 ----------------------------------------------------------------------------------------$20.00 --------BR $20.00 BR -----------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ----------------$24.00 ----------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR -----------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ----------------$24.00 ----------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR -----------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ----------------$20.00 ----------------$23.00 ----------------------------------------------------------------------------------------$20.00 --------BR $20.00 BR -----------------------------------------



Locality 04


--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ----------------$24.00 ----------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR -----------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ----------------$21.00 ----------------$24.00 ----------------------------------------------------------------------------------------$21.00 --------BR $21.00 BR -----------------------------------------

Part C, 352


2003 MRA


$36.00 $39.00 $13.00 $25.00 $38.00 $13.00 $24.00 $33.00 $11.00 $21.00 $21.00 $7.00 $14.00 $102.00 $31.00 $72.00 $61.00 $19.00 $41.00 $99.00 $33.00 $67.00 $66.00 $21.00 $43.00 $35.00 $11.00 $23.00 $45.00 $15.00 $31.00 $45.00 $14.00 $32.00 $24.00 $8.00 $16.00 $18.00 $3.00 $14.00 $21.00 $5.00 $16.00 $13.00 $4.00 $8.00 $17.00 $6.00 $11.00 $13.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 353


2003 MRA

86485-26 86485-TC 86486 86490 86490-26 86490-TC 86510 86510-26 86510-TC 86580 86580-26 86580-TC 86590 86590-26 86590-TC 86592 86592-26 86592-TC 86593 86593-26 86593-TC 86602 86602-26 86602-TC 86603 86603-26 86603-TC 86606 86606-26 86606-TC 86609 86609-26 86609-TC 86611 86611-26 86611-TC 86612 86612-26 86612-TC 86615 86615-26 86615-TC 86617 86617-26 86617-TC 86618 86618-26 86618-TC 86619 86619-26

$4.00 $8.00 --------$17.00 $5.00 $12.00 $13.00 $4.00 $8.00 $13.00 $4.00 $8.00 $18.00 $6.00 $12.00 $8.00 $2.00 $6.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $20.00 $6.00 $14.00 $24.00 $8.00 $16.00 $20.00 $6.00 $14.00 $23.00 $8.00 $15.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $29.00 $10.00 $19.00 $26.00 $8.00 $18.00 $21.00 $6.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

----------------$5.00 $75.00 ----------------$7.00 ----------------$8.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------$6.00 $80.00 ----------------$7.00 ----------------$9.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------$6.00 $81.00 ----------------$7.00 ----------------$10.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------$5.00 $75.00 ----------------$7.00 ----------------$8.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


----------------$6.00 $80.00 ----------------$7.00 ----------------$9.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------$6.00 $81.00 ----------------$7.00 ----------------$10.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 354


2003 MRA


$15.00 $16.00 $5.00 $11.00 $21.00 $6.00 $15.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $18.00 $5.00 $13.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $28.00 $10.00 $18.00 $24.00 $8.00 $16.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 355


2003 MRA


$7.00 $14.00 $53.00 $17.00 $36.00 $29.00 $10.00 $19.00 $23.00 $8.00 $15.00 $17.00 $5.00 $12.00 $20.00 $6.00 $14.00 $23.00 $7.00 $16.00 $24.00 $8.00 $16.00 $21.00 $7.00 $14.00 $24.00 $8.00 $16.00 $22.00 $7.00 $16.00 $20.00 $7.00 $14.00 $25.00 $8.00 $17.00 $22.00 $7.00 $15.00 $22.00 $7.00 $15.00 $21.00 $7.00 $14.00 $44.00 $14.00 $30.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 356


2003 MRA


$20.00 $6.00 $14.00 $21.00 $7.00 $15.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $33.00 $11.00 $21.00 $35.00 $11.00 $23.00 $24.00 $8.00 $16.00 $26.00 $8.00 $18.00 $32.00 $10.00 $21.00 $29.00 $10.00 $19.00 $22.00 $7.00 $15.00 $23.00 $7.00 $16.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $19.00 $6.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 357


2003 MRA


$13.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $23.00 $7.00 $16.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $44.00 $14.00 $30.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $23.00 $7.00 $16.00 $22.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 358


2003 MRA


$7.00 $15.00 $23.00 $7.00 $16.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $26.00 $8.00 $18.00 $24.00 $8.00 $16.00 $26.00 $8.00 $18.00 $97.00 $33.00 $64.00 $87.00 $28.00 $57.00 $74.00 $21.00 $51.00 $52.00 $15.00 $37.00 $108.00 $32.00 $75.00 $101.00 $29.00 $71.00 $64.00 $18.00 $44.00 $134.00 $39.00 $94.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 359


2003 MRA


$123.00 $36.00 $86.00 $96.00 $32.00 $64.00 BR BR BR $10.00 $3.00 $6.00 $44.00 $15.00 $29.00 $17.00 $6.00 $11.00 $13.00 $4.00 $8.00 $15.00 $4.00 $11.00 $14.00 $4.00 $10.00 $67.00 $11.00 $54.00 $91.00 $26.00 $64.00 $10.00 $3.00 $6.00 $10.00 $3.00 $6.00 $19.00 $6.00 $13.00 $7.00 $1.00 $6.00 $11.00 $3.00 $7.00 $83.00 $24.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 360


2003 MRA


$57.00 $19.00 $6.00 $13.00 $19.00 $3.00 $15.00 $23.00 $7.00 $16.00 $20.00 $6.00 $14.00 $21.00 $5.00 $16.00 $155.00 $45.00 $108.00 $155.00 $45.00 $108.00 $161.00 $48.00 $111.00 $18.00 $5.00 $13.00 $31.00 $8.00 $21.00 $35.00 $11.00 $23.00 $99.00 $29.00 $70.00 $25.00 $7.00 $18.00 $41.00 $12.00 $29.00 $20.00 $5.00 $15.00 $20.00 $6.00 $14.00 $53.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 361


2003 MRA


$16.00 $37.00 $53.00 $16.00 $37.00 $53.00 $16.00 $37.00 $65.00 $19.00 $44.00 $35.00 $12.00 $23.00 BR BR BR $40.00 $13.00 $26.00 $14.00 $5.00 $9.00 $18.00 $6.00 $12.00 $18.00 $6.00 $11.00 $5.00 $2.00 $3.00 $14.00 $4.00 $10.00 $11.00 $3.00 $8.00 $11.00 $3.00 $8.00 $18.00 $6.00 $12.00 $24.00 $8.00 $16.00 $16.00 $5.00 $11.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 362


2003 MRA


$12.00 $3.00 $8.00 $23.00 $7.00 $16.00 $14.00 $3.00 $11.00 $18.00 $6.00 $12.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $32.00 $11.00 $20.00 $25.00 $7.00 $18.00 $23.00 $8.00 $15.00 $26.00 $8.00 $18.00 $23.00 $7.00 $15.00 $15.00 $3.00 $11.00 $28.00 $9.00 $20.00 $24.00 $7.00 $17.00 $34.00 $11.00 $22.00 $26.00 $8.00 $18.00 $46.00 $15.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 363


2003 MRA


$31.00 $12.00 $4.00 $8.00 $5.00 $1.00 $3.00 $24.00 $8.00 $16.00 $24.00 $7.00 $17.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $16.00 $5.00 $11.00 $18.00 $6.00 $12.00 $13.00 $3.00 $8.00 $13.00 $3.00 $10.00 $11.00 $3.00 $8.00 $16.00 $4.00 $12.00 $20.00 $3.00 $17.00 $18.00 $5.00 $13.00 $7.00 $2.00 $5.00 $29.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

----------------------------------------------------------------$20.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------$20.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


----------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------$21.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 364


2003 MRA


$10.00 $19.00 $11.00 $3.00 $7.00 $15.00 $3.00 $12.00 $10.00 $3.00 $6.00 $8.00 $2.00 $6.00 $12.00 $4.00 $7.00 $35.00 $11.00 $23.00 $33.00 $13.00 $19.00 $44.00 $14.00 $31.00 $33.00 $10.00 $22.00 $11.00 $3.00 $8.00 BR BR BR $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 BR BR BR $26.00 $8.00 $18.00 BR BR BR


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------$20.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------$21.00 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 365


2003 MRA


$26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $13.00 $4.00 $9.00 $26.00 $8.00 $18.00 $26.00 $8.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 366


2003 MRA


$18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $27.00 $9.00 $19.00 $27.00 $7.00 $20.00 $27.00 $9.00 $19.00 $20.00 $6.00 $14.00 $23.00 $8.00 $15.00 $20.00 $6.00 $14.00 $35.00 $11.00 $23.00 $26.00 $8.00 $18.00 $38.00 $13.00 $24.00 $38.00 $13.00 $24.00 $13.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 367


2003 MRA


$4.00 $9.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $21.00 $6.00 $15.00 $19.00 $7.00 $12.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $40.00 $13.00 $26.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 368


2003 MRA


$42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $73.00 $23.00 $48.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 369


2003 MRA


$48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 370


2003 MRA


$13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 371


2003 MRA


$88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $46.00 $15.00 $31.00 $81.00 $26.00 $54.00 BR BR BR BR BR BR BR BR BR $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $594.00 $196.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



Locality 04


-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C, 372


2003 MRA


$398.00 BR BR BR $1,126.00 $371.00 $755.00 $59.00 $20.00 $39.00 BR BR BR $445.00 $445.00 BR $500.00 $500.00 BR $556.00 $556.00 BR $556.00 $556.00 BR $610.00 $610.00 BR $666.00 $666.00 BR $477.00 $477.00 BR $389.00 $389.00 BR $1,445.00 $1,445.00 BR BR BR BR BR BR BR $49.00 $37.00 $10.00 $54.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$82.00 $33.00 $49.00 $81.00

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$87.00 $34.00 $53.00 $86.00

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$87.00 $34.00 $53.00 $87.00

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$82.00 $33.00 $49.00 $81.00



Locality 04


--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$87.00 $34.00 $53.00 $86.00

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$87.00 $34.00 $53.00 $87.00

Part C, 373


2003 MRA


$16.00 $38.00 $59.00 $47.00 $11.00 ------------------------------------------------------------------------$70.00 $20.00 $48.00 $25.00 $7.00 $18.00 $18.00 $5.00 $13.00 $33.00 NC NC $82.00 $21.00 $59.00 $94.00 $33.00 $59.00 $82.00 NC $82.00 $104.00 $21.00 $82.00 $13.00 $3.00 $9.00 $46.00 $8.00 $38.00 $82.00 $21.00 $59.00 $104.00 $21.00 $82.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$22.00 $58.00 $78.00 $26.00 $52.00 $78.00 $32.00 $46.00 $678.00 $66.00 $612.00 $592.00 $57.00 $535.00 $26.00 $15.00 $10.00 ------------------------------------------------$36.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------

$23.00 $63.00 $83.00 $27.00 $56.00 $82.00 $32.00 $49.00 $725.00 $68.00 $657.00 $632.00 $58.00 $574.00 $27.00 $16.00 $11.00 ------------------------------------------------$37.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------

$23.00 $63.00 $84.00 $27.00 $57.00 $83.00 $33.00 $50.00 $728.00 $69.00 $660.00 $635.00 $59.00 $576.00 $28.00 $17.00 $12.00 ------------------------------------------------$38.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------

$22.00 $58.00 $78.00 $26.00 $52.00 $78.00 $32.00 $46.00 $678.00 $66.00 $612.00 $592.00 $57.00 $535.00 $26.00 $15.00 $10.00 ------------------------------------------------$36.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------



Locality 04


$23.00 $63.00 $83.00 $27.00 $56.00 $82.00 $32.00 $49.00 $725.00 $68.00 $657.00 $632.00 $58.00 $574.00 $27.00 $16.00 $11.00 ------------------------------------------------$37.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------

$23.00 $63.00 $84.00 $27.00 $57.00 $83.00 $33.00 $50.00 $728.00 $69.00 $660.00 $635.00 $59.00 $576.00 $28.00 $17.00 $12.00 ------------------------------------------------$38.00 BR BR --------------------------------------------------------BR ---------------------------------------------------------------------------------------------------------------------------------

Part C, 374


2003 MRA

88155 88155-26 88155-TC 88160 88160-26 88160-TC 88161 88161-26 88161-TC 88162 88162-26 88162-TC 88164 88164-26 88164-TC 88165 88165-26 88165-TC 88166 88166-26 88166-TC 88167 88167-26 88167-TC 88172 88172-26 88172-TC 88173 88173-26 88173-TC 88174 88174-26 88174-TC 88175 88175-26 88175-TC 88177 88177-26 88177-TC 88182 88182-26 88182-TC 88184 88185 88187 88188 88189 88199 88199-26 88199-TC

$14.00 $3.00 $10.00 $45.00 $14.00 $24.00 $64.00 $19.00 $37.00 $77.00 $22.00 $53.00 $54.00 $21.00 $33.00 $72.00 $33.00 $38.00 $82.00 $21.00 $59.00 $87.00 $26.00 $59.00 $70.00 $54.00 $14.00 $95.00 $95.00 $26.00 BR BR BR BR BR BR ------------------------$88.00 $33.00 $54.00 ----------------------------------------BR BR BR


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------$78.00 $30.00 $49.00 $70.00 $29.00 $42.00 $113.00 $45.00 $68.00 ------------------------------------------------------------------------------------------------$63.00 $41.00 $21.00 $167.00 $81.00 $86.00 ------------------------------------------------$33.00 $25.00 $8.00 $121.00 $41.00 $80.00 $81.00 $49.00 $80.00 $102.00 $126.00 -------------------------

------------------------$83.00 $31.00 $52.00 $74.00 $29.00 $45.00 $120.00 $46.00 $74.00 ------------------------------------------------------------------------------------------------$66.00 $43.00 $23.00 $176.00 $83.00 $93.00 ------------------------------------------------$35.00 $26.00 $9.00 $128.00 $42.00 $86.00 $87.00 $53.00 $83.00 $106.00 $129.00 -------------------------

------------------------$83.00 $31.00 $53.00 $75.00 $30.00 $45.00 $121.00 $47.00 $74.00 ------------------------------------------------------------------------------------------------$67.00 $43.00 $23.00 $178.00 $84.00 $94.00 ------------------------------------------------$35.00 $26.00 $9.00 $130.00 $42.00 $88.00 $87.00 $53.00 $85.00 $109.00 $133.00 -------------------------

------------------------$78.00 $30.00 $49.00 $70.00 $29.00 $42.00 $113.00 $45.00 $68.00 ------------------------------------------------------------------------------------------------$63.00 $41.00 $21.00 $167.00 $81.00 $86.00 ------------------------------------------------$33.00 $25.00 $8.00 $121.00 $41.00 $80.00 $81.00 $49.00 $80.00 $102.00 $126.00 -------------------------



Locality 04


------------------------$83.00 $31.00 $52.00 $74.00 $29.00 $45.00 $120.00 $46.00 $74.00 ------------------------------------------------------------------------------------------------$66.00 $43.00 $23.00 $176.00 $83.00 $93.00 ------------------------------------------------$35.00 $26.00 $9.00 $128.00 $42.00 $86.00 $87.00 $53.00 $83.00 $106.00 $129.00 -------------------------

------------------------$83.00 $31.00 $53.00 $75.00 $30.00 $45.00 $121.00 $47.00 $74.00 ------------------------------------------------------------------------------------------------$67.00 $43.00 $23.00 $178.00 $84.00 $94.00 ------------------------------------------------$35.00 $26.00 $9.00 $130.00 $42.00 $88.00 $87.00 $53.00 $85.00 $109.00 $133.00 -------------------------

Part C, 375


2003 MRA


$243.00 $73.00 $170.00 $256.00 $76.00 $177.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $24.00 $19.00 $5.00 $53.00 $42.00 $11.00 $70.00 $54.00 $14.00 $108.00 $86.00 $21.00 $210.00 $168.00 $41.00 $322.00 $258.00 $64.00 $23.00 $19.00 $4.00 $23.00 $7.00 $16.00 $23.00 $7.00 $16.00 $21.00 $6.00 $15.00 $26.00 $13.00 $14.00 $43.00 $43.00 NC $61.00 $61.00


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

------------------------------------------------------------------------------------------------$17.00 $5.00 $11.00 $35.00 $8.00 $27.00 $49.00 $13.00 $36.00 $80.00 $43.00 $36.00 $333.00 $95.00 $238.00 $506.00 $169.00 $338.00 $24.00 $15.00 $9.00 $105.00 $31.00 $75.00 $74.00 $14.00 $60.00 $83.00 $25.00 $58.00 $96.00 $31.00 $65.00 $113.00 --------BR $152.00 $98.00

------------------------------------------------------------------------------------------------$18.00 $5.00 $12.00 $38.00 $9.00 $29.00 $53.00 $13.00 $39.00 $84.00 $45.00 $39.00 $353.00 $98.00 $255.00 $536.00 $174.00 $363.00 $25.00 $15.00 $10.00 $112.00 $32.00 $80.00 $79.00 $14.00 $64.00 $88.00 $26.00 $62.00 $102.00 $32.00 $70.00 $117.00 --------BR $158.00 $100.00

------------------------------------------------------------------------------------------------$19.00 $6.00 $13.00 $38.00 $9.00 $29.00 $53.00 $14.00 $40.00 $85.00 $45.00 $40.00 $356.00 $99.00 $257.00 $541.00 $176.00 $365.00 $26.00 $15.00 $10.00 $113.00 $32.00 $81.00 $79.00 $15.00 $65.00 $89.00 $26.00 $62.00 $103.00 $32.00 $71.00 $120.00 --------BR $160.00 $101.00

------------------------------------------------------------------------------------------------$17.00 $5.00 $11.00 $35.00 $8.00 $27.00 $49.00 $13.00 $36.00 $80.00 $43.00 $36.00 $333.00 $95.00 $238.00 $506.00 $169.00 $338.00 $24.00 $15.00 $9.00 $105.00 $31.00 $75.00 $74.00 $14.00 $60.00 $83.00 $25.00 $58.00 $96.00 $31.00 $65.00 $96.00 --------BR $152.00 $98.00



Locality 04


------------------------------------------------------------------------------------------------$18.00 $5.00 $12.00 $38.00 $9.00 $29.00 $53.00 $13.00 $39.00 $84.00 $45.00 $39.00 $353.00 $98.00 $255.00 $536.00 $174.00 $363.00 $25.00 $15.00 $10.00 $112.00 $32.00 $80.00 $79.00 $14.00 $64.00 $88.00 $26.00 $62.00 $102.00 $32.00 $70.00 $100.00 --------BR $158.00 $100.00

------------------------------------------------------------------------------------------------$19.00 $6.00 $13.00 $38.00 $9.00 $29.00 $53.00 $14.00 $40.00 $85.00 $45.00 $40.00 $356.00 $99.00 $257.00 $541.00 $176.00 $365.00 $26.00 $15.00 $10.00 $113.00 $32.00 $81.00 $79.00 $15.00 $65.00 $89.00 $26.00 $62.00 $103.00 $32.00 $71.00 $102.00 --------BR $160.00 $101.00

Part C, 376


2003 MRA


NC $54.00 $54.00 NC $51.00 $51.00 NC $102.00 $70.00 $33.00 $53.00 $36.00 $17.00 ------------------------------------------------------------------------$53.00 $36.00 $17.00 ------------------------$96.00 $66.00 $28.00 $191.00 $145.00 $44.00 ------------------------$108.00 $80.00 $26.00 $108.00 $80.00 $26.00 $108.00 $80.00 $26.00 ---------------------------------


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$54.00 $190.00 --------BR $56.00 --------BR $105.00 $71.00 $33.00 $55.00 $35.00 $20.00 $110.00 $72.00 $38.00 $68.00 $44.00 $24.00 $96.00 $30.00 $66.00 $115.00 $41.00 $74.00 $185.00 $45.00 $141.00 $101.00 $42.00 $59.00 $372.00 $86.00 $285.00 $77.00 $31.00 $46.00 $170.00 $92.00 $78.00 $224.00 $135.00 $89.00 $93.00 $51.00 $42.00 $131.00 $62.00 $69.00 $160.00

$58.00 $198.00 --------BR $58.00 --------BR $110.00 $74.00 $36.00 $58.00 $36.00 $22.00 $115.00 $74.00 $41.00 $71.00 $46.00 $25.00 $102.00 $31.00 $71.00 $122.00 $42.00 $80.00 $197.00 $46.00 $151.00 $106.00 $43.00 $63.00 $395.00 $89.00 $307.00 $82.00 $32.00 $49.00 $178.00 $93.00 $84.00 $233.00 $138.00 $95.00 $97.00 $52.00 $45.00 $137.00 $63.00 $74.00 $169.00

$58.00 $202.00 --------BR $60.00 --------BR $111.00 $75.00 $36.00 $59.00 $36.00 $22.00 $116.00 $75.00 $41.00 $72.00 $46.00 $26.00 $102.00 $32.00 $71.00 $123.00 $43.00 $80.00 $198.00 $47.00 $152.00 $107.00 $44.00 $64.00 $399.00 $90.00 $309.00 $82.00 $32.00 $50.00 $179.00 $94.00 $85.00 $236.00 $139.00 $97.00 $98.00 $52.00 $46.00 $139.00 $64.00 $75.00 $171.00

$54.00 $152.00 --------BR $42.00 --------BR $105.00 $71.00 $33.00 $55.00 $35.00 $20.00 $110.00 $72.00 $38.00 $68.00 $44.00 $24.00 $96.00 $30.00 $66.00 $115.00 $41.00 $74.00 $185.00 $45.00 $141.00 $101.00 $42.00 $59.00 $372.00 $86.00 $285.00 $77.00 $31.00 $46.00 $170.00 $92.00 $78.00 $224.00 $135.00 $89.00 $93.00 $51.00 $42.00 $131.00 $62.00 $69.00 $160.00



Locality 04


$58.00 $157.00 --------BR $43.00 --------BR $110.00 $74.00 $36.00 $58.00 $36.00 $22.00 $115.00 $74.00 $41.00 $71.00 $46.00 $25.00 $102.00 $31.00 $71.00 $122.00 $42.00 $80.00 $197.00 $46.00 $151.00 $106.00 $43.00 $63.00 $395.00 $89.00 $307.00 $82.00 $32.00 $49.00 $178.00 $93.00 $84.00 $233.00 $138.00 $95.00 $97.00 $52.00 $45.00 $137.00 $63.00 $74.00 $169.00

$58.00 $161.00 --------BR $45.00 --------BR $111.00 $75.00 $36.00 $59.00 $36.00 $22.00 $116.00 $75.00 $41.00 $72.00 $46.00 $26.00 $102.00 $32.00 $71.00 $123.00 $43.00 $80.00 $198.00 $47.00 $152.00 $107.00 $44.00 $64.00 $399.00 $90.00 $309.00 $82.00 $32.00 $50.00 $179.00 $94.00 $85.00 $236.00 $139.00 $97.00 $98.00 $52.00 $46.00 $139.00 $64.00 $75.00 $171.00

Part C, 377


2003 MRA

88361-26 88361-TC 88362 88362-26 88362-TC 88363 88364 88364-26 88364-TC 88365 88365-26 88365-TC 88366 88366-26 88366-TC 88367 88367-26 88367-TC 88368 88368-26 88368-TC 88369 88369-26 88369-TC 88371 88371-26 88371-TC 88372 88372-26 88372-TC 88373 88373-26 88373-TC 88374 88374-26 88374-TC 88375 88377 88377-26 88377-TC 88380 88380-26 88380-TC 88381 88381-26 88381-TC 88387 88387-26 88387-TC 88388

----------------BR BR BR --------------------------------$24.00 $24.00 BR ------------------------------------------------------------------------------------------------$34.00 $10.00 $23.00 $38.00 $11.00 $26.00 --------------------------------------------------------------------------------BR BR BR ---------------------------------------------------------


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$67.00 $94.00 $281.00 $123.00 $157.00 $25.00 $144.00 $38.00 $106.00 $190.00 $50.00 $140.00 $280.00 $71.00 $210.00 $114.00 $39.00 $75.00 $123.00 $45.00 $78.00 $116.00 $35.00 $81.00 --------$20.00 ----------------$20.00 --------$80.00 $24.00 $57.00 $367.00 $51.00 $317.00 $55.00 $438.00 $73.00 $365.00 $156.00 $64.00 $92.00 $126.00 $28.00 $98.00 $46.00 $36.00 $10.00 $38.00

$68.00 $101.00 $296.00 $127.00 $169.00 $26.00 $153.00 $40.00 $114.00 $202.00 $51.00 $150.00 $298.00 $73.00 $225.00 $121.00 $40.00 $81.00 $129.00 $46.00 $83.00 $123.00 $36.00 $87.00 --------$21.00 ----------------$21.00 --------$85.00 $24.00 $61.00 $392.00 $52.00 $340.00 $57.00 $466.00 $74.00 $392.00 $165.00 $66.00 $99.00 $134.00 $29.00 $105.00 $48.00 $38.00 $11.00 $40.00

$69.00 $101.00 $299.00 $129.00 $170.00 $27.00 $155.00 $40.00 $114.00 $203.00 $52.00 $151.00 $300.00 $74.00 $226.00 $122.00 $40.00 $82.00 $130.00 $46.00 $84.00 $124.00 $36.00 $88.00 --------$21.00 ----------------$21.00 --------$85.00 $24.00 $61.00 $394.00 $52.00 $341.00 $59.00 $469.00 $75.00 $394.00 $167.00 $67.00 $100.00 $135.00 $29.00 $106.00 $49.00 $38.00 $11.00 $40.00

$67.00 $94.00 $281.00 $123.00 $157.00 $22.00 $144.00 $38.00 $106.00 $190.00 $50.00 $140.00 $280.00 $71.00 $210.00 $114.00 $39.00 $75.00 $123.00 $45.00 $78.00 $116.00 $35.00 $81.00 --------$20.00 ----------------$20.00 --------$80.00 $24.00 $57.00 $367.00 $51.00 $317.00 $55.00 $438.00 $73.00 $365.00 $156.00 $64.00 $92.00 $126.00 $28.00 $98.00 $46.00 $36.00 $10.00 $38.00



Locality 04


$68.00 $101.00 $296.00 $127.00 $169.00 $23.00 $153.00 $40.00 $114.00 $202.00 $51.00 $150.00 $298.00 $73.00 $225.00 $121.00 $40.00 $81.00 $129.00 $46.00 $83.00 $123.00 $36.00 $87.00 --------$21.00 ----------------$21.00 --------$85.00 $24.00 $61.00 $392.00 $52.00 $340.00 $57.00 $466.00 $74.00 $392.00 $165.00 $66.00 $99.00 $134.00 $29.00 $105.00 $48.00 $38.00 $11.00 $40.00

$69.00 $101.00 $299.00 $129.00 $170.00 $23.00 $155.00 $40.00 $114.00 $203.00 $52.00 $151.00 $300.00 $74.00 $226.00 $122.00 $40.00 $82.00 $130.00 $46.00 $84.00 $124.00 $36.00 $88.00 --------$21.00 ----------------$21.00 --------$85.00 $24.00 $61.00 $394.00 $52.00 $341.00 $59.00 $469.00 $75.00 $394.00 $167.00 $67.00 $100.00 $135.00 $29.00 $106.00 $49.00 $38.00 $11.00 $40.00

Part C, 378


2003 MRA

88388-26 88388-TC 88399 88399-26 88399-TC 89049 89050 89050-26 89050-TC 89051 89051-26 89051-TC 89055 89055-26 89055-TC 89060 89060-26 89060-TC 89125 89125-26 89125-TC 89160 89160-26 89160-TC 89190 89190-26 89190-TC 89220 89230 G0124 G0141 G0416 G0416-26 G0416-TC G0452-26 G0455

----------------BR BR BR --------$10.00 $3.00 $6.00 $13.00 $4.00 $8.00 BR BR BR $13.00 $5.00 $8.00 $14.00 $4.00 $10.00 $6.00 $2.00 $4.00 $10.00 $3.00 $6.00 -------------------------------------------------------------------------


Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$27.00 $11.00 ------------------------$282.00 --------------------------------------------------------------------------------$20.00 --------------------------------------------------------------------------------$18.00 $6.00 $36.00 $36.00 $570.00 $172.00 $398.00 $20.00 $142.00

$28.00 $12.00 ------------------------$300.00 --------------------------------------------------------------------------------$21.00 --------------------------------------------------------------------------------$19.00 $6.00 $37.00 $37.00 $604.00 $177.00 $427.00 $21.00 $151.00

$28.00 $12.00 ------------------------$304.00 --------------------------------------------------------------------------------$21.00 --------------------------------------------------------------------------------$19.00 $7.00 $38.00 $38.00 $608.00 $179.00 $429.00 $21.00 $156.00

$27.00 $11.00 ------------------------$74.00 --------------------------------------------------------------------------------$20.00 --------------------------------------------------------------------------------$18.00 $6.00 $36.00 $36.00 $570.00 $172.00 $398.00 $20.00 $84.00



Locality 04


$28.00 $12.00 ------------------------$77.00 --------------------------------------------------------------------------------$21.00 --------------------------------------------------------------------------------$19.00 $6.00 $37.00 $37.00 $604.00 $177.00 $427.00 $21.00 $88.00

$28.00 $12.00 ------------------------$80.00 --------------------------------------------------------------------------------$21.00 --------------------------------------------------------------------------------$19.00 $7.00 $38.00 $38.00 $608.00 $179.00 $429.00 $21.00 $93.00

Part C, 379



2003 MRA ----------------$4.00 $4.00 BR BR BR BR BR BR BR ----------------------------------------------------------------------------------------$85.00 $93.00 $110.00 $32.00 $32.00 $143.00 $94.00 $74.00 $112.00 $112.00 $104.00 $49.00 $77.00 BR BR $46.00 $82.00 $76.00 $226.00 BR $80.00 $125.00 -------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$27.00 $14.00 $27.00 $14.00 $27.00 $14.00 ----------------------------------------$15.00 $146.00 $162.00 $71.00 $73.00 $94.00 $93.00 $142.00 $123.00 $147.00 $70.00 $102.00 $114.00 $118.00 $38.00 $28.00 $183.00 $194.00 $68.00 $119.00 $112.00 --------$55.00 $98.00 ----------------$41.00 $92.00 $81.00 $116.00 --------$96.00 $139.00 $1,054.00 $910.00 $509.00 $355.00 $719.00 $486.00

$29.00 $14.00 $29.00 $14.00 $29.00 $14.00 ----------------------------------------$16.00 $150.00 $166.00 $72.00 $75.00 $96.00 $95.00 $145.00 $126.00 $151.00 $72.00 $104.00 $117.00 $121.00 $39.00 $29.00 $190.00 $203.00 $71.00 $124.00 $115.00 --------$57.00 $102.00 ----------------$43.00 $97.00 $84.00 $120.00 --------$99.00 $143.00 $1,094.00 $942.00 $527.00 $368.00 $745.00 $503.00

$29.00 $15.00 $29.00 $15.00 $29.00 $15.00 ----------------------------------------$16.00 $153.00 $170.00 $74.00 $77.00 $98.00 $98.00 $148.00 $129.00 $154.00 $73.00 $106.00 $120.00 $124.00 $40.00 $30.00 $193.00 $206.00 $73.00 $128.00 $118.00 --------$59.00 $105.00 ----------------$44.00 $99.00 $86.00 $124.00 --------$102.00 $148.00 $1,135.00 $974.00 $544.00 $379.00 $769.00 $519.00

$27.00 $14.00 $27.00 $14.00 $27.00 $14.00 ----------------------------------------$15.00 $142.00 $157.00 $70.00 $72.00 $94.00 $92.00 $140.00 $122.00 $147.00 $70.00 $101.00 $114.00 $117.00 $34.00 $28.00 $143.00 $123.00 $68.00 $108.00 $104.00 --------$55.00 $85.00 ----------------$22.00 $50.00 $81.00 $116.00 --------$96.00 $139.00 $1,054.00 $910.00 $509.00 $355.00 $719.00 $486.00

$29.00 $14.00 $29.00 $14.00 $29.00 $14.00 ----------------------------------------$16.00 $145.00 $161.00 $72.00 $74.00 $96.00 $94.00 $143.00 $125.00 $150.00 $71.00 $104.00 $116.00 $120.00 $35.00 $29.00 $147.00 $126.00 $71.00 $112.00 $107.00 --------$57.00 $87.00 ----------------$23.00 $52.00 $84.00 $120.00 --------$99.00 $143.00 $1,094.00 $942.00 $527.00 $368.00 $745.00 $503.00

$29.00 $15.00 $29.00 $15.00 $29.00 $15.00 ----------------------------------------$16.00 $148.00 $165.00 $73.00 $76.00 $98.00 $97.00 $147.00 $128.00 $153.00 $73.00 $106.00 $119.00 $123.00 $36.00 $29.00 $150.00 $129.00 $73.00 $115.00 $109.00 --------$59.00 $90.00 ----------------$23.00 $54.00 $86.00 $124.00 --------$102.00 $148.00 $1,135.00 $974.00 $544.00 $379.00 $769.00 $519.00


Part C, 380


Medicine CPT Code

2003 MRA

90959 90960 90961 90962 90963 90964 90965 90966 90967 90968 90969 90970 90997 90999 91010 91010-26 91010-TC 91013 91013-26 91013-TC 91020 91020-26 91020-TC 91022 91022-26 91022-TC 91030 91030-26 91030-TC 91034 91034-26 91034-TC 91035 91035-26 91035-TC 91037 91037-26 91037-TC 91038 91038-26 91038-TC 91040 91040-26 91040-TC 91065 91065-26 91065-TC 91110 91110-26 91110-TC

------------------------------------------------------------------------------------------------$115.00 BR $116.00 $76.00 $32.00 ------------------------$60.00 $49.00 $9.00 ------------------------$57.00 $47.00 $8.00 ------------------------------------------------------------------------------------------------------------------------$34.00 $23.00 $14.00 -------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$330.00 $316.00 $265.00 $204.00 $607.00 $530.00 $505.00 $264.00 $20.00 $17.00 $17.00 $9.00 $104.00 --------$191.00 $75.00 $116.00 $25.00 $11.00 $14.00 $253.00 $84.00 $169.00 $182.00 $84.00 $98.00 $147.00 $53.00 $95.00 $205.00 $58.00 $147.00 $516.00 $95.00 $422.00 $173.00 $57.00 $117.00 $481.00 $64.00 $417.00 $465.00 $56.00 $410.00 $84.00 $11.00 $72.00 $948.00 $212.00 $736.00

$342.00 $327.00 $275.00 $212.00 $628.00 $550.00 $523.00 $274.00 $21.00 $18.00 $18.00 $9.00 $108.00 --------$203.00 $78.00 $124.00 $26.00 $11.00 $15.00 $268.00 $87.00 $181.00 $192.00 $86.00 $105.00 $156.00 $54.00 $102.00 $218.00 $60.00 $158.00 $551.00 $98.00 $453.00 $184.00 $59.00 $125.00 $514.00 $66.00 $448.00 $497.00 $57.00 $440.00 $90.00 $12.00 $78.00 $1,009.00 $219.00 $790.00

$352.00 $337.00 $283.00 $218.00 $648.00 $567.00 $539.00 $282.00 $21.00 $19.00 $18.00 $9.00 $111.00 --------$206.00 $81.00 $125.00 $27.00 $11.00 $15.00 $272.00 $89.00 $183.00 $194.00 $88.00 $106.00 $158.00 $56.00 $102.00 $221.00 $62.00 $159.00 $556.00 $102.00 $454.00 $186.00 $60.00 $126.00 $518.00 $68.00 $449.00 $499.00 $58.00 $441.00 $90.00 $12.00 $78.00 $1,017.00 $224.00 $793.00

$330.00 $316.00 $265.00 $204.00 $607.00 $530.00 $505.00 $264.00 $20.00 $17.00 $17.00 $9.00 $104.00 --------$191.00 $75.00 $116.00 $25.00 $11.00 $14.00 $253.00 $84.00 $169.00 $182.00 $84.00 $98.00 $147.00 $53.00 $95.00 $205.00 $58.00 $147.00 $516.00 $95.00 $422.00 $173.00 $57.00 $117.00 $481.00 $64.00 $417.00 $465.00 $56.00 $410.00 $84.00 $11.00 $72.00 $948.00 $212.00 $736.00

$342.00 $327.00 $275.00 $212.00 $628.00 $550.00 $523.00 $274.00 $21.00 $18.00 $18.00 $9.00 $108.00 --------$203.00 $78.00 $124.00 $26.00 $11.00 $15.00 $268.00 $87.00 $181.00 $192.00 $86.00 $105.00 $156.00 $54.00 $102.00 $218.00 $60.00 $158.00 $551.00 $98.00 $453.00 $184.00 $59.00 $125.00 $514.00 $66.00 $448.00 $497.00 $57.00 $440.00 $90.00 $12.00 $78.00 $1,009.00 $219.00 $790.00

$352.00 $337.00 $283.00 $218.00 $648.00 $567.00 $539.00 $282.00 $21.00 $19.00 $18.00 $9.00 $111.00 --------$206.00 $81.00 $125.00 $27.00 $11.00 $15.00 $272.00 $89.00 $183.00 $194.00 $88.00 $106.00 $158.00 $56.00 $102.00 $221.00 $62.00 $159.00 $556.00 $102.00 $454.00 $186.00 $60.00 $126.00 $518.00 $68.00 $449.00 $499.00 $58.00 $441.00 $90.00 $12.00 $78.00 $1,017.00 $224.00 $793.00


Part C, 381


Medicine CPT Code

2003 MRA

91111 91111-26 91111-TC 91112 91112-26 91112-TC 91117 91120 91120-26 91120-TC 91122 91122-26 91122-TC 91132 91132-26 91132-TC 91133 91133-26 91133-TC 91200 91200-26 91200-TC 91299 91299-26 91299-TC 92002 92004 92012 92014 92015 92018 92019 92020 92025 92025-26 92025-TC 92060 92060-26 92060-TC 92065 92065-26 92065-TC 92071 92072 92081 92081-26 92081-TC 92082 92082-26 92082-TC

--------------------------------------------------------------------------------$169.00 $122.00 $37.00 BR $28.00 BR BR $34.00 BR ------------------------BR BR BR $63.00 $98.00 $53.00 $75.00 $34.00 $80.00 $70.00 $31.00 ------------------------$40.00 $32.00 $7.00 $34.00 $19.00 $6.00 ----------------$32.00 $19.00 $6.00 $48.00 $24.00 $9.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$774.00 $59.00 $715.00 $1,156.00 $123.00 $1,033.00 $155.00 $456.00 $57.00 $399.00 $247.00 $102.00 $145.00 $167.00 $32.00 $135.00 $185.00 $39.00 $146.00 $34.00 $15.00 $20.00 ------------------------$88.00 $162.00 $93.00 $135.00 $22.00 $161.00 $80.00 $29.00 $41.00 $22.00 $19.00 $71.00 $42.00 $28.00 $58.00 $20.00 $38.00 $42.00 $148.00 $37.00 $18.00 $19.00 $52.00 $24.00 $28.00

$828.00 $61.00 $768.00 $1,236.00 $127.00 $1,109.00 $161.00 $487.00 $59.00 $428.00 $262.00 $106.00 $156.00 $178.00 $34.00 $145.00 $197.00 $40.00 $157.00 $36.00 $15.00 $21.00 ------------------------$92.00 $169.00 $97.00 $141.00 $23.00 $166.00 $82.00 $30.00 $44.00 $23.00 $21.00 $74.00 $43.00 $31.00 $61.00 $21.00 $40.00 $43.00 $154.00 $39.00 $19.00 $20.00 $55.00 $25.00 $30.00

$833.00 $62.00 $770.00 $1,243.00 $131.00 $1,112.00 $166.00 $491.00 $61.00 $430.00 $267.00 $110.00 $157.00 $181.00 $36.00 $145.00 $199.00 $41.00 $158.00 $37.00 $15.00 $22.00 ------------------------$93.00 $172.00 $99.00 $143.00 $23.00 $170.00 $84.00 $31.00 $44.00 $23.00 $21.00 $75.00 $44.00 $31.00 $62.00 $21.00 $41.00 $44.00 $156.00 $39.00 $19.00 $21.00 $56.00 $25.00 $31.00

$774.00 $59.00 $715.00 $1,156.00 $123.00 $1,033.00 $155.00 $456.00 $57.00 $399.00 $247.00 $102.00 $145.00 $167.00 $32.00 $135.00 $185.00 $39.00 $146.00 $34.00 $15.00 $20.00 ------------------------$53.00 $110.00 $58.00 $89.00 $22.00 $161.00 $80.00 $23.00 $41.00 $22.00 $19.00 $71.00 $42.00 $28.00 $58.00 $20.00 $38.00 $37.00 $114.00 $37.00 $18.00 $19.00 $52.00 $24.00 $28.00

$828.00 $61.00 $768.00 $1,236.00 $127.00 $1,109.00 $161.00 $487.00 $59.00 $428.00 $262.00 $106.00 $156.00 $178.00 $34.00 $145.00 $197.00 $40.00 $157.00 $36.00 $15.00 $21.00 ------------------------$55.00 $114.00 $60.00 $92.00 $22.00 $166.00 $82.00 $24.00 $44.00 $23.00 $21.00 $74.00 $43.00 $31.00 $61.00 $21.00 $40.00 $38.00 $118.00 $39.00 $19.00 $20.00 $55.00 $25.00 $30.00

$833.00 $62.00 $770.00 $1,243.00 $131.00 $1,112.00 $166.00 $491.00 $61.00 $430.00 $267.00 $110.00 $157.00 $181.00 $36.00 $145.00 $199.00 $41.00 $158.00 $37.00 $15.00 $22.00 ------------------------$56.00 $116.00 $62.00 $94.00 $23.00 $170.00 $84.00 $24.00 $44.00 $23.00 $21.00 $75.00 $44.00 $31.00 $62.00 $21.00 $41.00 $39.00 $120.00 $39.00 $19.00 $21.00 $56.00 $25.00 $31.00


Part C, 382


Medicine CPT Code

2003 MRA

92083 92083-26 92083-TC 92100 92132 92132-26 92132-TC 92133 92133-26 92133-TC 92134 92134-26 92134-TC 92136 92136-26 92136-TC 92140 92145 92145-26 92145-TC 92225 92226 92227 92228 92228-26 92228-TC 92230 92235 92235-26 92235-TC 92240 92240-26 92240-TC 92250 92250-26 92250-TC 92260 92265 92265-26 92265-TC 92270 92270-26 92270-TC 92275 92275-26 92275-TC 92283 92283-26 92283-TC 92284

$59.00 $31.00 $14.00 $40.00 ------------------------------------------------------------------------$93.00 $29.00 $63.00 $38.00 ------------------------$45.00 $39.00 --------------------------------$58.00 $104.00 $46.00 $53.00 $132.00 $60.00 $67.00 $40.00 $24.00 $7.00 $20.00 $53.00 $37.00 $10.00 $64.00 $45.00 $19.00 $80.00 $56.00 $17.00 $24.00 $10.00 $5.00 $192.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$70.00 $31.00 $39.00 $86.00 $38.00 $21.00 $17.00 $48.00 $31.00 $17.00 $49.00 $32.00 $18.00 $97.00 $34.00 $63.00 $69.00 $17.00 $9.00 $7.00 $29.00 $27.00 $16.00 $38.00 $23.00 $15.00 $63.00 $118.00 $52.00 $67.00 $274.00 $70.00 $204.00 $85.00 $27.00 $58.00 $20.00 $86.00 $48.00 $38.00 $99.00 $46.00 $53.00 $160.00 $60.00 $100.00 $60.00 $10.00 $49.00 $66.00

$73.00 $32.00 $42.00 $91.00 $40.00 $22.00 $18.00 $50.00 $32.00 $19.00 $51.00 $33.00 $19.00 $103.00 $35.00 $68.00 $72.00 $18.00 $10.00 $8.00 $31.00 $28.00 $17.00 $39.00 $24.00 $16.00 $67.00 $125.00 $53.00 $72.00 $291.00 $73.00 $219.00 $90.00 $27.00 $63.00 $21.00 $91.00 $49.00 $41.00 $105.00 $47.00 $57.00 $169.00 $61.00 $108.00 $64.00 $11.00 $53.00 $70.00

$74.00 $32.00 $42.00 $92.00 $41.00 $22.00 $18.00 $51.00 $32.00 $19.00 $52.00 $33.00 $19.00 $104.00 $36.00 $68.00 $73.00 $18.00 $10.00 $8.00 $31.00 $29.00 $17.00 $40.00 $24.00 $16.00 $68.00 $126.00 $54.00 $72.00 $293.00 $73.00 $219.00 $91.00 $28.00 $63.00 $21.00 $92.00 $50.00 $42.00 $106.00 $48.00 $58.00 $170.00 $62.00 $109.00 $64.00 $11.00 $53.00 $71.00

$70.00 $31.00 $39.00 $38.00 $38.00 $21.00 $17.00 $48.00 $31.00 $17.00 $49.00 $32.00 $18.00 $97.00 $34.00 $63.00 $30.00 $17.00 $9.00 $7.00 $23.00 $21.00 $16.00 $38.00 $23.00 $15.00 $37.00 $118.00 $52.00 $67.00 $274.00 $70.00 $204.00 $85.00 $27.00 $58.00 $12.00 $86.00 $48.00 $38.00 $99.00 $46.00 $53.00 $160.00 $60.00 $100.00 $60.00 $10.00 $49.00 $66.00

$73.00 $32.00 $42.00 $39.00 $40.00 $22.00 $18.00 $50.00 $32.00 $19.00 $51.00 $33.00 $19.00 $103.00 $35.00 $68.00 $31.00 $18.00 $10.00 $8.00 $24.00 $22.00 $17.00 $39.00 $24.00 $16.00 $39.00 $125.00 $53.00 $72.00 $291.00 $73.00 $219.00 $90.00 $27.00 $63.00 $13.00 $91.00 $49.00 $41.00 $105.00 $47.00 $57.00 $169.00 $61.00 $108.00 $64.00 $11.00 $53.00 $70.00

$74.00 $32.00 $42.00 $39.00 $41.00 $22.00 $18.00 $51.00 $32.00 $19.00 $52.00 $33.00 $19.00 $104.00 $36.00 $68.00 $32.00 $18.00 $10.00 $8.00 $24.00 $22.00 $17.00 $40.00 $24.00 $16.00 $40.00 $126.00 $54.00 $72.00 $293.00 $73.00 $219.00 $91.00 $28.00 $63.00 $13.00 $92.00 $50.00 $42.00 $106.00 $48.00 $58.00 $170.00 $62.00 $109.00 $64.00 $11.00 $53.00 $71.00


Part C, 383


Medicine CPT Code

2003 MRA

92284-26 92284-TC 92285 92285-26 92285-TC 92286 92286-26 92286-TC 92287 92287-26 92287-TC 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92340 92341 92342 92358 92370 92371 92499 92499-26 92499-TC 92502 92504 92507 92508 92511 92512 92516 92520 92521 92522 92523 92524 92526 92531 92532 92533 92534 92537 92537-26 92537-TC

$151.00 $46.00 $26.00 $12.00 $6.00 $91.00 $53.00 $29.00 $99.00 ----------------$86.00 $78.00 $89.00 $70.00 $54.00 $44.00 $59.00 $39.00 $14.00 $44.00 $32.00 $43.00 $43.00 $24.00 $35.00 $18.00 BR BR BR $101.00 $24.00 $40.00 $42.00 $81.00 $46.00 $36.00 $47.00 --------------------------------$48.00 $10.00 $14.00 $41.00 BR -------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$14.00 $52.00 $22.00 $4.00 $19.00 $42.00 $25.00 $17.00 $148.00 $51.00 $96.00 $105.00 $110.00 $127.00 $105.00 $86.00 $78.00 $99.00 $82.00 $45.00 $38.00 $39.00 $44.00 $48.00 $12.00 $34.00 $13.00 ------------------------$109.00 $33.00 $87.00 $26.00 $122.00 $66.00 $76.00 $83.00 $122.00 $102.00 $213.00 $99.00 $95.00 --------------------------------$44.00 $35.00 $9.00

$14.00 $56.00 $24.00 $4.00 $20.00 $44.00 $25.00 $19.00 $156.00 $53.00 $104.00 $110.00 $115.00 $133.00 $110.00 $91.00 $83.00 $104.00 $87.00 $48.00 $40.00 $41.00 $46.00 $50.00 $13.00 $35.00 $14.00 ------------------------$114.00 $35.00 $90.00 $27.00 $129.00 $70.00 $81.00 $88.00 $127.00 $106.00 $222.00 $103.00 $98.00 --------------------------------$46.00 $36.00 $10.00

$15.00 $57.00 $25.00 $4.00 $21.00 $45.00 $26.00 $19.00 $158.00 $53.00 $104.00 $112.00 $117.00 $134.00 $112.00 $93.00 $84.00 $105.00 $88.00 $49.00 $41.00 $41.00 $47.00 $51.00 $14.00 $36.00 $14.00 ------------------------$117.00 $35.00 $92.00 $27.00 $131.00 $72.00 $82.00 $90.00 $130.00 $108.00 $226.00 $105.00 $100.00 --------------------------------$47.00 $37.00 $10.00

$14.00 $52.00 $22.00 $4.00 $19.00 $42.00 $25.00 $17.00 $148.00 $51.00 $96.00 $67.00 $62.00 $71.00 $53.00 $39.00 $24.00 $37.00 $25.00 $45.00 $38.00 $21.00 $27.00 $30.00 $12.00 $18.00 $13.00 ------------------------$109.00 $11.00 $87.00 $26.00 $44.00 $32.00 $26.00 $47.00 $122.00 $102.00 $213.00 $99.00 $95.00 --------------------------------$44.00 $35.00 $9.00

$14.00 $56.00 $24.00 $4.00 $20.00 $44.00 $25.00 $19.00 $156.00 $53.00 $104.00 $69.00 $64.00 $73.00 $54.00 $40.00 $25.00 $37.00 $26.00 $48.00 $40.00 $22.00 $28.00 $31.00 $13.00 $19.00 $14.00 ------------------------$114.00 $11.00 $90.00 $27.00 $46.00 $34.00 $27.00 $49.00 $127.00 $106.00 $222.00 $103.00 $98.00 --------------------------------$46.00 $36.00 $10.00

$15.00 $57.00 $25.00 $4.00 $21.00 $45.00 $26.00 $19.00 $158.00 $53.00 $104.00 $71.00 $65.00 $74.00 $55.00 $42.00 $26.00 $38.00 $26.00 $49.00 $41.00 $22.00 $29.00 $32.00 $14.00 $19.00 $14.00 ------------------------$117.00 $11.00 $92.00 $27.00 $47.00 $35.00 $28.00 $50.00 $130.00 $108.00 $226.00 $105.00 $100.00 --------------------------------$47.00 $37.00 $10.00


Part C, 384


Medicine CPT Code

2003 MRA

92538 92538-26 92538-TC 92540 92540-26 92540-TC 92541 92541-26 92541-TC 92542 92542-26 92542-TC 92544 92544-26 92544-TC 92545 92545-26 92545-TC 92546 92546-26 92546-TC 92547 92548 92548-26 92548-TC 92550 92551 92552 92553 92555 92556 92557 92560 92561 92562 92563 92564 92565 92567 92568 92570 92571 92572 92575 92576 92577 92579 92582 92583 92584

------------------------------------------------$37.00 $25.00 $9.00 $33.00 $20.00 $10.00 $26.00 $16.00 $8.00 $22.00 $14.00 $8.00 $29.00 $17.00 $9.00 $21.00 $92.00 $30.00 $59.00 --------$17.00 $16.00 $24.00 $14.00 $21.00 $46.00 $23.00 $27.00 $15.00 $14.00 $17.00 $15.00 $20.00 $14.00 --------$14.00 $3.00 $11.00 $17.00 $28.00 $28.00 $28.00 $34.00 $94.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$23.00 $18.00 $5.00 $112.00 $88.00 $24.00 $27.00 $23.00 $4.00 $31.00 $28.00 $3.00 $18.00 $16.00 $3.00 $17.00 $15.00 $2.00 $111.00 $16.00 $94.00 $6.00 $110.00 $29.00 $81.00 $24.00 $13.00 $33.00 $40.00 $25.00 $40.00 $41.00 --------$41.00 $50.00 $33.00 $30.00 $17.00 $16.00 $18.00 $36.00 $29.00 $38.00 $77.00 $38.00 $18.00 $47.00 $72.00 $56.00 $79.00

$24.00 $18.00 $6.00 $116.00 $91.00 $25.00 $28.00 $24.00 $4.00 $32.00 $29.00 $4.00 $19.00 $16.00 $3.00 $18.00 $15.00 $3.00 $119.00 $17.00 $102.00 $7.00 $117.00 $30.00 $87.00 $24.00 $14.00 $36.00 $43.00 $27.00 $43.00 $43.00 --------$44.00 $53.00 $36.00 $32.00 $19.00 $17.00 $18.00 $37.00 $32.00 $41.00 $83.00 $41.00 $19.00 $49.00 $78.00 $60.00 $85.00

$24.00 $18.00 $6.00 $118.00 $92.00 $26.00 $28.00 $24.00 $4.00 $33.00 $29.00 $4.00 $20.00 $16.00 $3.00 $18.00 $15.00 $3.00 $120.00 $17.00 $102.00 $7.00 $119.00 $31.00 $88.00 $25.00 $14.00 $36.00 $43.00 $27.00 $43.00 $44.00 --------$45.00 $54.00 $36.00 $33.00 $19.00 $17.00 $19.00 $38.00 $32.00 $42.00 $84.00 $42.00 $20.00 $50.00 $79.00 $61.00 $85.00

$23.00 $18.00 $5.00 $112.00 $88.00 $24.00 $27.00 $23.00 $4.00 $31.00 $28.00 $3.00 $18.00 $16.00 $3.00 $17.00 $15.00 $2.00 $111.00 $16.00 $94.00 $6.00 $110.00 $29.00 $81.00 $24.00 $13.00 $33.00 $40.00 $25.00 $40.00 $37.00 --------$41.00 $50.00 $33.00 $30.00 $17.00 $12.00 $17.00 $33.00 $29.00 $38.00 $77.00 $38.00 $18.00 $42.00 $72.00 $56.00 $79.00

$24.00 $18.00 $6.00 $116.00 $91.00 $25.00 $28.00 $24.00 $4.00 $32.00 $29.00 $4.00 $19.00 $16.00 $3.00 $18.00 $15.00 $3.00 $119.00 $17.00 $102.00 $7.00 $117.00 $30.00 $87.00 $24.00 $14.00 $36.00 $43.00 $27.00 $43.00 $38.00 --------$44.00 $53.00 $36.00 $32.00 $19.00 $13.00 $18.00 $35.00 $32.00 $41.00 $83.00 $41.00 $19.00 $44.00 $78.00 $60.00 $85.00

$24.00 $18.00 $6.00 $118.00 $92.00 $26.00 $28.00 $24.00 $4.00 $33.00 $29.00 $4.00 $20.00 $16.00 $3.00 $18.00 $15.00 $3.00 $120.00 $17.00 $102.00 $7.00 $119.00 $31.00 $88.00 $25.00 $14.00 $36.00 $43.00 $27.00 $43.00 $39.00 --------$45.00 $54.00 $36.00 $33.00 $19.00 $13.00 $19.00 $36.00 $32.00 $42.00 $84.00 $42.00 $20.00 $45.00 $79.00 $61.00 $85.00


Part C, 385


Medicine CPT Code

2003 MRA

92585 92585-26 92585-TC 92586 92587 92587-26 92587-TC 92588 92588-26 92588-TC 92590 92591 92592 92593 92594 92595 92596 92597 92603 92604 92605 92606 92607 92608 92609 92610 92611 92612 92613 92614 92615 92616 92617 92618 92620 92621 92625 92626 92627 92640 92700 92920 92924 92928 92933 92937 92941 92943 92950 92953

$114.00 $52.00 $70.00 $70.00 $58.00 $8.00 $49.00 $78.00 $20.00 $57.00 $41.00 BR BR BR BR BR $22.00 $96.00 $88.00 $60.00 BR BR $109.00 $22.00 $59.00 $42.00 $46.00 $173.00 BR $134.00 BR $183.00 BR --------------------------------------------------------BR --------------------------------------------------------$203.00 $35.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$146.00 $30.00 $116.00 $91.00 $24.00 $20.00 $4.00 $36.00 $32.00 $4.00 ------------------------------------------------$45.00 $80.00 $167.00 $98.00 $104.00 $92.00 $139.00 $58.00 $121.00 $94.00 $96.00 $202.00 $43.00 $159.00 $38.00 $228.00 $47.00 $38.00 $104.00 $25.00 $77.00 $99.00 $24.00 $125.00 --------$648.00 $770.00 $720.00 $806.00 $720.00 $807.00 $807.00 $337.00 $13.00

$156.00 $31.00 $125.00 $98.00 $25.00 $21.00 $4.00 $38.00 $33.00 $5.00 ------------------------------------------------$49.00 $83.00 $174.00 $103.00 $107.00 $96.00 $145.00 $60.00 $126.00 $98.00 $101.00 $214.00 $45.00 $168.00 $39.00 $240.00 $49.00 $39.00 $108.00 $25.00 $80.00 $102.00 $25.00 $130.00 --------$694.00 $825.00 $771.00 $863.00 $771.00 $865.00 $864.00 $354.00 $13.00

$157.00 $31.00 $126.00 $99.00 $26.00 $21.00 $4.00 $38.00 $33.00 $5.00 ------------------------------------------------$50.00 $85.00 $177.00 $104.00 $110.00 $98.00 $147.00 $61.00 $128.00 $100.00 $104.00 $217.00 $47.00 $171.00 $41.00 $244.00 $50.00 $41.00 $110.00 $26.00 $82.00 $104.00 $26.00 $132.00 --------$766.00 $910.00 $851.00 $952.00 $851.00 $954.00 $953.00 $366.00 $14.00

$146.00 $30.00 $116.00 $91.00 $24.00 $20.00 $4.00 $36.00 $32.00 $4.00 ------------------------------------------------$45.00 $80.00 $136.00 $75.00 $99.00 $80.00 $139.00 $58.00 $121.00 $81.00 $96.00 $76.00 $43.00 $76.00 $37.00 $114.00 $47.00 $37.00 $92.00 $21.00 $69.00 $85.00 $20.00 $107.00 --------$648.00 $770.00 $720.00 $806.00 $720.00 $807.00 $807.00 $213.00 $13.00

$156.00 $31.00 $125.00 $98.00 $25.00 $21.00 $4.00 $38.00 $33.00 $5.00 ------------------------------------------------$49.00 $83.00 $141.00 $78.00 $103.00 $82.00 $145.00 $60.00 $126.00 $84.00 $101.00 $79.00 $45.00 $79.00 $39.00 $118.00 $49.00 $38.00 $95.00 $22.00 $72.00 $87.00 $21.00 $110.00 --------$694.00 $825.00 $771.00 $863.00 $771.00 $865.00 $864.00 $221.00 $13.00

$157.00 $31.00 $126.00 $99.00 $26.00 $21.00 $4.00 $38.00 $33.00 $5.00 ------------------------------------------------$50.00 $85.00 $144.00 $79.00 $106.00 $85.00 $147.00 $61.00 $128.00 $86.00 $104.00 $82.00 $47.00 $81.00 $40.00 $122.00 $50.00 $40.00 $97.00 $22.00 $73.00 $89.00 $21.00 $112.00 --------$766.00 $910.00 $851.00 $952.00 $851.00 $954.00 $953.00 $232.00 $14.00


Part C, 386


Medicine CPT Code

2003 MRA

92960 92961 92970 92971 92973 92974 92975 92977 92978 92978-26 92978-TC 92979 92979-26 92979-TC 92986 92987 92990 92992 92993 92997 92998 93000 93005 93010 93015 93016 93017 93018 93024 93024-26 93024-TC 93025 93025-26 93025-TC 93040 93041 93042 93050 93050-26 93050-TC 93224 93225 93226 93227 93228 93229 93260 93260-26 93260-TC 93261

$162.00 $239.00 $201.00 $100.00 $174.00 $197.00 $400.00 $302.00 $269.00 $95.00 $170.00 $163.00 $76.00 $86.00 $1,222.00 $1,271.00 $974.00 BR BR $765.00 $331.00 $26.00 $16.00 $12.00 $104.00 $25.00 $63.00 $54.00 $111.00 $71.00 $42.00 $277.00 ----------------$14.00 $31.00 $9.00 ------------------------$159.00 $46.00 $83.00 $50.00 -------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$226.00 $306.00 $218.00 $119.00 $210.00 $192.00 $464.00 $68.00 --------$113.00 ----------------$90.00 --------$1,573.00 $1,621.00 $1,279.00 ----------------$779.00 $383.00 $19.00 $9.00 $9.00 $83.00 $25.00 $42.00 $16.00 $122.00 $64.00 $59.00 $172.00 $41.00 $131.00 $14.00 $6.00 $8.00 $19.00 $9.00 $10.00 $99.00 $28.00 $41.00 $29.00 $29.00 $776.00 $73.00 $50.00 $24.00 $66.00

$238.00 $327.00 $231.00 $128.00 $225.00 $205.00 $496.00 $74.00 --------$120.00 ----------------$96.00 --------$1,685.00 $1,736.00 $1,371.00 ----------------$835.00 $410.00 $20.00 $10.00 $10.00 $87.00 $26.00 $45.00 $17.00 $128.00 $65.00 $63.00 $183.00 $42.00 $141.00 $15.00 $7.00 $8.00 $20.00 $10.00 $10.00 $105.00 $31.00 $44.00 $30.00 $30.00 $833.00 $77.00 $51.00 $25.00 $69.00

$243.00 $357.00 $249.00 $140.00 $248.00 $226.00 $547.00 $79.00 --------$131.00 ----------------$105.00 --------$1,847.00 $1,900.00 $1,501.00 ----------------$922.00 $452.00 $20.00 $10.00 $10.00 $89.00 $26.00 $46.00 $17.00 $130.00 $67.00 $64.00 $184.00 $43.00 $141.00 $16.00 $7.00 $9.00 $21.00 $10.00 $11.00 $106.00 $31.00 $44.00 $31.00 $31.00 $837.00 $78.00 $52.00 $26.00 $70.00

$137.00 $306.00 $218.00 $119.00 $210.00 $192.00 $464.00 $68.00 --------$113.00 ----------------$90.00 --------$1,573.00 $1,621.00 $1,279.00 ----------------$779.00 $383.00 $19.00 $9.00 $9.00 $83.00 $25.00 $42.00 $16.00 $122.00 $64.00 $59.00 $172.00 $41.00 $131.00 $14.00 $6.00 $8.00 $19.00 $9.00 $10.00 $99.00 $28.00 $41.00 $29.00 $29.00 $776.00 $73.00 $50.00 $24.00 $66.00

$143.00 $327.00 $231.00 $128.00 $225.00 $205.00 $496.00 $74.00 --------$120.00 ----------------$96.00 --------$1,685.00 $1,736.00 $1,371.00 ----------------$835.00 $410.00 $20.00 $10.00 $10.00 $87.00 $26.00 $45.00 $17.00 $128.00 $65.00 $63.00 $183.00 $42.00 $141.00 $15.00 $7.00 $8.00 $20.00 $10.00 $10.00 $105.00 $31.00 $44.00 $30.00 $30.00 $833.00 $77.00 $51.00 $25.00 $69.00

$147.00 $357.00 $249.00 $140.00 $248.00 $226.00 $547.00 $79.00 --------$131.00 ----------------$105.00 --------$1,847.00 $1,900.00 $1,501.00 ----------------$922.00 $452.00 $20.00 $10.00 $10.00 $89.00 $26.00 $46.00 $17.00 $130.00 $67.00 $64.00 $184.00 $43.00 $141.00 $16.00 $7.00 $9.00 $21.00 $10.00 $11.00 $106.00 $31.00 $44.00 $31.00 $31.00 $837.00 $78.00 $52.00 $26.00 $70.00


Part C, 387


Medicine CPT Code

2003 MRA

93261-26 93261-TC 93268 93270 93271 93272 93278 93278-26 93278-TC 93279 93279-26 93279-TC 93280 93280-26 93280-TC 93281 93281-26 93281-TC 93282 93282-26 93282-TC 93283 93283-26 93283-TC 93284 93284-26 93284-TC 93285 93285-26 93285-TC 93286 93286-26 93286-TC 93287 93287-26 93287-TC 93288 93288-26 93288-TC 93289 93289-26 93289-TC 93290 93290-26 93290-TC 93291 93291-26 93291-TC 93292 93292-26

----------------$109.00 $46.00 $90.00 $28.00 $58.00 $24.00 $44.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$43.00 $24.00 $220.00 $10.00 $182.00 $28.00 $33.00 $14.00 $19.00 $54.00 $36.00 $19.00 $64.00 $43.00 $21.00 $75.00 $50.00 $25.00 $69.00 $47.00 $22.00 $89.00 $64.00 $25.00 $99.00 $70.00 $29.00 $46.00 $29.00 $17.00 $30.00 $17.00 $13.00 $40.00 $26.00 $14.00 $40.00 $24.00 $17.00 $72.00 $51.00 $21.00 $34.00 $24.00 $10.00 $40.00 $24.00 $16.00 $36.00 $24.00

$44.00 $25.00 $235.00 $11.00 $195.00 $29.00 $35.00 $14.00 $21.00 $57.00 $37.00 $20.00 $67.00 $44.00 $23.00 $78.00 $51.00 $27.00 $72.00 $48.00 $23.00 $93.00 $66.00 $27.00 $103.00 $72.00 $31.00 $48.00 $30.00 $19.00 $31.00 $17.00 $14.00 $42.00 $26.00 $15.00 $42.00 $24.00 $18.00 $75.00 $52.00 $23.00 $36.00 $25.00 $11.00 $42.00 $25.00 $17.00 $38.00 $25.00

$45.00 $26.00 $237.00 $11.00 $196.00 $30.00 $35.00 $14.00 $21.00 $58.00 $37.00 $21.00 $68.00 $45.00 $23.00 $79.00 $52.00 $27.00 $73.00 $49.00 $24.00 $95.00 $67.00 $28.00 $105.00 $74.00 $31.00 $49.00 $31.00 $19.00 $32.00 $18.00 $14.00 $43.00 $27.00 $16.00 $43.00 $25.00 $18.00 $76.00 $53.00 $23.00 $37.00 $25.00 $12.00 $43.00 $25.00 $17.00 $39.00 $25.00

$43.00 $24.00 $220.00 $10.00 $182.00 $28.00 $33.00 $14.00 $19.00 $54.00 $36.00 $19.00 $64.00 $43.00 $21.00 $75.00 $50.00 $25.00 $69.00 $47.00 $22.00 $89.00 $64.00 $25.00 $99.00 $70.00 $29.00 $46.00 $29.00 $17.00 $30.00 $17.00 $13.00 $40.00 $26.00 $14.00 $40.00 $24.00 $17.00 $72.00 $51.00 $21.00 $34.00 $24.00 $10.00 $40.00 $24.00 $16.00 $36.00 $24.00

$44.00 $25.00 $235.00 $11.00 $195.00 $29.00 $35.00 $14.00 $21.00 $57.00 $37.00 $20.00 $67.00 $44.00 $23.00 $78.00 $51.00 $27.00 $72.00 $48.00 $23.00 $93.00 $66.00 $27.00 $103.00 $72.00 $31.00 $48.00 $30.00 $19.00 $31.00 $17.00 $14.00 $42.00 $26.00 $15.00 $42.00 $24.00 $18.00 $75.00 $52.00 $23.00 $36.00 $25.00 $11.00 $42.00 $25.00 $17.00 $38.00 $25.00

$45.00 $26.00 $237.00 $11.00 $196.00 $30.00 $35.00 $14.00 $21.00 $58.00 $37.00 $21.00 $68.00 $45.00 $23.00 $79.00 $52.00 $27.00 $73.00 $49.00 $24.00 $95.00 $67.00 $28.00 $105.00 $74.00 $31.00 $49.00 $31.00 $19.00 $32.00 $18.00 $14.00 $43.00 $27.00 $16.00 $43.00 $25.00 $18.00 $76.00 $53.00 $23.00 $37.00 $25.00 $12.00 $43.00 $25.00 $17.00 $39.00 $25.00


Part C, 388


Medicine CPT Code

2003 MRA

93292-TC 93293 93293-26 93293-TC 93294 93295 93296 93297 93298 93303 93303-26 93303-TC 93304 93304-26 93304-TC 93306 93306-26 93306-TC 93307 93307-26 93307-TC 93308 93308-26 93308-TC 93312 93312-26 93312-TC 93313 93314 93314-26 93314-TC 93315 93315-26 93315-TC 93316 93317 93317-26 93317-TC 93318 93318-26 93318-TC 93320 93320-26 93320-TC 93321 93321-26 93321-TC 93325 93325-26 93325-TC

------------------------------------------------------------------------$215.00 $70.00 $144.00 $114.00 $43.00 $73.00 ------------------------$196.00 $56.00 $144.00 $118.00 $46.00 $75.00 $322.00 $140.00 $182.00 $76.00 $212.00 $65.00 $144.00 $287.00 $144.00 $141.00 $78.00 $236.00 $95.00 $141.00 BR $114.00 BR $86.00 $30.00 $65.00 $50.00 $10.00 $42.00 $114.00 $4.00 $110.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$12.00 $57.00 $17.00 $40.00 $38.00 $76.00 $28.00 $30.00 $30.00 $257.00 $71.00 $186.00 $168.00 $41.00 $127.00 $246.00 $71.00 $175.00 $141.00 $50.00 $91.00 $134.00 $29.00 $106.00 $333.00 $135.00 $197.00 $26.00 $326.00 $117.00 $209.00 $894.00 $158.00 $736.00 $44.00 --------$120.00 --------$867.00 $131.00 $736.00 $59.00 $20.00 $38.00 $29.00 $8.00 $21.00 $27.00 $4.00 $24.00

$13.00 $61.00 $18.00 $43.00 $39.00 $78.00 $30.00 $31.00 $31.00 $273.00 $73.00 $200.00 $179.00 $42.00 $137.00 $261.00 $73.00 $188.00 $149.00 $52.00 $98.00 $143.00 $30.00 $113.00 $351.00 $139.00 $212.00 $26.00 $347.00 $122.00 $225.00 $953.00 $163.00 $790.00 $45.00 --------$125.00 --------$926.00 $136.00 $790.00 $62.00 $21.00 $41.00 $31.00 $9.00 $23.00 $29.00 $4.00 $26.00

$13.00 $62.00 $18.00 $44.00 $41.00 $81.00 $30.00 $32.00 $32.00 $276.00 $75.00 $201.00 $180.00 $43.00 $137.00 $264.00 $74.00 $190.00 $151.00 $53.00 $98.00 $144.00 $30.00 $114.00 $356.00 $142.00 $213.00 $28.00 $354.00 $128.00 $226.00 $959.00 $167.00 $792.00 $47.00 --------$131.00 --------$934.00 $141.00 $792.00 $62.00 $21.00 $41.00 $32.00 $9.00 $23.00 $29.00 $4.00 $26.00

$12.00 $57.00 $17.00 $40.00 $38.00 $76.00 $28.00 $30.00 $30.00 $257.00 $71.00 $186.00 $168.00 $41.00 $127.00 $246.00 $71.00 $175.00 $141.00 $50.00 $91.00 $134.00 $29.00 $106.00 $333.00 $135.00 $197.00 $26.00 $326.00 $117.00 $209.00 $894.00 $158.00 $736.00 $44.00 --------$120.00 --------$867.00 $131.00 $736.00 $59.00 $20.00 $38.00 $29.00 $8.00 $21.00 $27.00 $4.00 $24.00

$13.00 $61.00 $18.00 $43.00 $39.00 $78.00 $30.00 $31.00 $31.00 $273.00 $73.00 $200.00 $179.00 $42.00 $137.00 $261.00 $73.00 $188.00 $149.00 $52.00 $98.00 $143.00 $30.00 $113.00 $351.00 $139.00 $212.00 $26.00 $347.00 $122.00 $225.00 $953.00 $163.00 $790.00 $45.00 --------$125.00 --------$926.00 $136.00 $790.00 $62.00 $21.00 $41.00 $31.00 $9.00 $23.00 $29.00 $4.00 $26.00

$13.00 $62.00 $18.00 $44.00 $41.00 $81.00 $30.00 $32.00 $32.00 $276.00 $75.00 $201.00 $180.00 $43.00 $137.00 $264.00 $74.00 $190.00 $151.00 $53.00 $98.00 $144.00 $30.00 $114.00 $356.00 $142.00 $213.00 $28.00 $354.00 $128.00 $226.00 $959.00 $167.00 $792.00 $47.00 --------$131.00 --------$934.00 $141.00 $792.00 $62.00 $21.00 $41.00 $32.00 $9.00 $23.00 $29.00 $4.00 $26.00


Part C, 389


Medicine CPT Code

2003 MRA

93350 93350-26 93350-TC 93351 93351-26 93351-TC 93352 93355 93451 93451-26 93451-TC 93452 93452-26 93452-TC 93453 93453-26 93453-TC 93454 93454-26 93454-TC 93455 93455-26 93455-TC 93456 93456-26 93456-TC 93457 93457-26 93457-TC 93458 93458-26 93458-TC 93459 93459-26 93459-TC 93460 93460-26 93460-TC 93461 93461-26 93461-TC 93462 93463 93464 93464-26 93464-TC 93503 93505 93505-26 93505-TC

$216.00 $77.00 $66.00 --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$187.00 $318.00 $248.00 $74.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$260.00 $79.00 $181.00 $293.00 $95.00 $199.00 $37.00 $255.00 $852.00 $169.00 $682.00 $967.00 $296.00 $671.00 $1,249.00 $392.00 $857.00 $982.00 $300.00 $682.00 $1,143.00 $347.00 $796.00 $1,231.00 $385.00 $846.00 $1,392.00 $432.00 $960.00 $1,179.00 $367.00 $812.00 $1,303.00 $414.00 $890.00 $1,399.00 $461.00 $938.00 $1,599.00 $509.00 $1,091.00 $247.00 $111.00 $297.00 $98.00 $200.00 $148.00 $838.00 $274.00 $565.00

$276.00 $82.00 $194.00 $311.00 $97.00 $213.00 $39.00 $264.00 $913.00 $180.00 $733.00 $1,035.00 $314.00 $721.00 $1,338.00 $417.00 $921.00 $1,052.00 $320.00 $732.00 $1,225.00 $370.00 $855.00 $1,319.00 $410.00 $908.00 $1,491.00 $461.00 $1,030.00 $1,263.00 $391.00 $872.00 $1,396.00 $441.00 $955.00 $1,499.00 $491.00 $1,007.00 $1,713.00 $542.00 $1,171.00 $265.00 $115.00 $315.00 $100.00 $215.00 $153.00 $897.00 $291.00 $606.00

$279.00 $83.00 $196.00 $314.00 $99.00 $215.00 $40.00 $274.00 $932.00 $196.00 $736.00 $1,066.00 $342.00 $724.00 $1,381.00 $456.00 $925.00 $1,085.00 $350.00 $735.00 $1,263.00 $404.00 $859.00 $1,361.00 $448.00 $913.00 $1,538.00 $503.00 $1,035.00 $1,303.00 $427.00 $876.00 $1,441.00 $482.00 $959.00 $1,549.00 $537.00 $1,012.00 $1,769.00 $593.00 $1,176.00 $291.00 $119.00 $319.00 $103.00 $216.00 $161.00 $927.00 $318.00 $609.00

$260.00 $79.00 $181.00 $293.00 $95.00 $199.00 $37.00 $255.00 $852.00 $169.00 $682.00 $967.00 $296.00 $671.00 $1,249.00 $392.00 $857.00 $982.00 $300.00 $682.00 $1,143.00 $347.00 $796.00 $1,231.00 $385.00 $846.00 $1,392.00 $432.00 $960.00 $1,179.00 $367.00 $812.00 $1,303.00 $414.00 $890.00 $1,399.00 $461.00 $938.00 $1,599.00 $509.00 $1,091.00 $247.00 $111.00 $297.00 $98.00 $200.00 $148.00 $838.00 $274.00 $565.00

$276.00 $82.00 $194.00 $311.00 $97.00 $213.00 $39.00 $264.00 $913.00 $180.00 $733.00 $1,035.00 $314.00 $721.00 $1,338.00 $417.00 $921.00 $1,052.00 $320.00 $732.00 $1,225.00 $370.00 $855.00 $1,319.00 $410.00 $908.00 $1,491.00 $461.00 $1,030.00 $1,263.00 $391.00 $872.00 $1,396.00 $441.00 $955.00 $1,499.00 $491.00 $1,007.00 $1,713.00 $542.00 $1,171.00 $265.00 $115.00 $315.00 $100.00 $215.00 $153.00 $897.00 $291.00 $606.00

$279.00 $83.00 $196.00 $314.00 $99.00 $215.00 $40.00 $274.00 $932.00 $196.00 $736.00 $1,066.00 $342.00 $724.00 $1,381.00 $456.00 $925.00 $1,085.00 $350.00 $735.00 $1,263.00 $404.00 $859.00 $1,361.00 $448.00 $913.00 $1,538.00 $503.00 $1,035.00 $1,303.00 $427.00 $876.00 $1,441.00 $482.00 $959.00 $1,549.00 $537.00 $1,012.00 $1,769.00 $593.00 $1,176.00 $291.00 $119.00 $319.00 $103.00 $216.00 $161.00 $927.00 $318.00 $609.00


Part C, 390


Medicine CPT Code

2003 MRA

93530 93530-26 93530-TC 93531 93531-26 93531-TC 93532 93532-26 93532-TC 93533 93533-26 93533-TC 93561 93561-26 93561-TC 93562 93562-26 93562-TC 93563 93564 93565 93566 93567 93568 93571 93571-26 93571-TC 93572 93572-26 93572-TC 93580 93581 93582 93583 93600 93600-26 93600-TC 93602 93602-26 93602-TC 93603 93603-26 93603-TC 93609 93609-26 93609-TC 93610 93610-26 93610-TC 93612

$872.00 $250.00 $634.00 $2,268.00 $467.00 $1,815.00 $2,317.00 $569.00 $1,766.00 $2,131.00 $352.00 $1,766.00 $59.00 $47.00 $20.00 $46.00 $33.00 $13.00 ------------------------------------------------$270.00 $93.00 $170.00 $222.00 $74.00 $155.00 $974.00 $1,303.00 ----------------$198.00 $129.00 $73.00 $159.00 $119.00 $42.00 $187.00 $127.00 $63.00 $578.00 $481.00 $101.00 $214.00 $166.00 $52.00 $224.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

--------$257.00 ----------------$502.00 ----------------$628.00 ----------------$419.00 ----------------$29.00 ----------------$9.00 --------$69.00 $73.00 $54.00 $188.00 $156.00 $169.00 --------$113.00 ----------------$90.00 --------$1,157.00 $1,584.00 $792.00 $894.00 --------$139.00 ----------------$136.00 ----------------$136.00 ----------------$325.00 ----------------$193.00 -----------------

--------$272.00 ----------------$529.00 ----------------$670.00 ----------------$447.00 ----------------$30.00 ----------------$9.00 --------$73.00 $78.00 $58.00 $201.00 $167.00 $181.00 --------$120.00 ----------------$96.00 --------$1,237.00 $1,699.00 $847.00 $956.00 --------$148.00 ----------------$145.00 ----------------$145.00 ----------------$346.00 ----------------$206.00 -----------------

--------$294.00 ----------------$569.00 ----------------$734.00 ----------------$488.00 ----------------$32.00 ----------------$10.00 --------$80.00 $86.00 $63.00 $208.00 $175.00 $187.00 --------$131.00 ----------------$105.00 --------$1,359.00 $1,876.00 $931.00 $1,050.00 --------$161.00 ----------------$158.00 ----------------$158.00 ----------------$377.00 ----------------$224.00 -----------------

--------$257.00 ----------------$502.00 ----------------$628.00 ----------------$419.00 ----------------$29.00 ----------------$9.00 --------$69.00 $73.00 $54.00 $55.00 $62.00 $56.00 --------$113.00 ----------------$90.00 --------$1,157.00 $1,584.00 $792.00 $894.00 --------$139.00 ----------------$136.00 ----------------$136.00 ----------------$325.00 ----------------$193.00 -----------------

--------$272.00 ----------------$529.00 ----------------$670.00 ----------------$447.00 ----------------$30.00 ----------------$9.00 --------$73.00 $78.00 $58.00 $58.00 $66.00 $60.00 --------$120.00 ----------------$96.00 --------$1,237.00 $1,699.00 $847.00 $956.00 --------$148.00 ----------------$145.00 ----------------$145.00 ----------------$346.00 ----------------$206.00 -----------------

--------$294.00 ----------------$569.00 ----------------$734.00 ----------------$488.00 ----------------$32.00 ----------------$10.00 --------$80.00 $86.00 $63.00 $64.00 $73.00 $65.00 --------$131.00 ----------------$105.00 --------$1,359.00 $1,876.00 $931.00 $1,050.00 --------$161.00 ----------------$158.00 ----------------$158.00 ----------------$377.00 ----------------$224.00 -----------------


Part C, 391


Medicine CPT Code

2003 MRA

93612-26 93612-TC 93613 93615 93615-26 93615-TC 93616 93616-26 93616-TC 93618 93618-26 93618-TC 93619 93619-26 93619-TC 93620 93620-26 93620-TC 93621 93621-26 93621-TC 93622 93622-26 93622-TC 93623 93623-26 93623-TC 93624 93624-26 93624-TC 93631 93631-26 93631-TC 93640 93640-26 93640-TC 93641 93641-26 93641-TC 93642 93642-26 93642-TC 93644 93644-26 93644-TC 93650 93653 93654 93655 93656

$167.00 $61.00 $377.00 $62.00 $49.00 $12.00 $94.00 $82.00 $12.00 $399.00 $258.00 $148.00 $717.00 $444.00 $290.00 $358.00 $272.00 $91.00 BR $769.00 BR BR $771.00 BR BR $167.00 BR $333.00 $256.00 $74.00 $651.00 $420.00 $239.00 $467.00 $230.00 $269.00 $613.00 $360.00 $269.00 $549.00 $295.00 $269.00 ------------------------$639.00 ---------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$191.00 --------$470.00 --------$58.00 ----------------$73.00 ----------------$277.00 ----------------$474.00 ----------------$752.00 ----------------$137.00 ----------------$200.00 ----------------$186.00 ----------------$308.00 ----------------$470.00 ----------------$226.00 ----------------$383.00 --------$481.00 $318.00 $163.00 $305.00 $192.00 $113.00 $712.00 $1,003.00 $1,337.00 $502.00 $1,337.00

$204.00 --------$503.00 --------$60.00 ----------------$74.00 ----------------$296.00 ----------------$505.00 ----------------$801.00 ----------------$146.00 ----------------$214.00 ----------------$198.00 ----------------$329.00 ----------------$501.00 ----------------$241.00 ----------------$409.00 --------$515.00 $339.00 $176.00 $319.00 $198.00 $121.00 $763.00 $1,075.00 $1,432.00 $537.00 $1,433.00

$222.00 --------$553.00 --------$62.00 ----------------$77.00 ----------------$322.00 ----------------$551.00 ----------------$873.00 ----------------$159.00 ----------------$233.00 ----------------$216.00 ----------------$359.00 ----------------$550.00 ----------------$263.00 ----------------$446.00 --------$547.00 $370.00 $177.00 $323.00 $201.00 $122.00 $838.00 $1,182.00 $1,575.00 $591.00 $1,576.00

$191.00 --------$470.00 --------$58.00 ----------------$73.00 ----------------$277.00 ----------------$474.00 ----------------$752.00 ----------------$137.00 ----------------$200.00 ----------------$186.00 ----------------$308.00 ----------------$470.00 ----------------$226.00 ----------------$383.00 --------$481.00 $318.00 $163.00 $305.00 $192.00 $113.00 $712.00 $1,003.00 $1,337.00 $502.00 $1,337.00

$204.00 --------$503.00 --------$60.00 ----------------$74.00 ----------------$296.00 ----------------$505.00 ----------------$801.00 ----------------$146.00 ----------------$214.00 ----------------$198.00 ----------------$329.00 ----------------$501.00 ----------------$241.00 ----------------$409.00 --------$515.00 $339.00 $176.00 $319.00 $198.00 $121.00 $763.00 $1,075.00 $1,432.00 $537.00 $1,433.00

$222.00 --------$553.00 --------$62.00 ----------------$77.00 ----------------$322.00 ----------------$551.00 ----------------$873.00 ----------------$159.00 ----------------$233.00 ----------------$216.00 ----------------$359.00 ----------------$550.00 ----------------$263.00 ----------------$446.00 --------$547.00 $370.00 $177.00 $323.00 $201.00 $122.00 $838.00 $1,182.00 $1,575.00 $591.00 $1,576.00


Part C, 392


Medicine CPT Code

2003 MRA

93657 93660 93660-26 93660-TC 93662 93662-26 93662-TC 93701 93701-26 93701-TC 93702 93724 93724-26 93724-TC 93740 93740-26 93740-TC 93750 93770 93770-26 93770-TC 93784 93786 93788 93790 93797 93798 93799 93799-26 93799-TC 93880 93880-26 93880-TC 93882 93882-26 93882-TC 93886 93886-26 93886-TC 93888 93888-26 93888-TC 93890 93890-26 93890-TC 93892 93892-26 93892-TC 93893 93893-26

--------$162.00 $103.00 $61.00 BR $158.00 BR $36.00 $9.00 $27.00 --------$411.00 $259.00 $148.00 $17.00 $12.00 $5.00 --------NC NC NC NC NC NC NC $17.00 $38.00 BR BR BR $176.00 $31.00 $144.00 $117.00 $21.00 $95.00 $215.00 $50.00 $162.00 $142.00 $33.00 $109.00 -----------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$502.00 $173.00 $105.00 $68.00 --------$159.00 --------$26.00 ----------------$115.00 $300.00 $270.00 $30.00 $9.00 ----------------$63.00 NC NC NC NC NC NC NC $18.00 $28.00 ------------------------$207.00 $45.00 $162.00 $141.00 $29.00 $112.00 $215.00 $53.00 $162.00 $160.00 $29.00 $131.00 $220.00 $58.00 $162.00 $166.00 $69.00 $97.00 $165.00 $67.00

$538.00 $181.00 $108.00 $73.00 --------$164.00 --------$28.00 ----------------$124.00 $310.00 $278.00 $32.00 $9.00 ----------------$66.00 NC NC NC NC NC NC NC $19.00 $29.00 ------------------------$221.00 $47.00 $174.00 $151.00 $31.00 $120.00 $229.00 $56.00 $173.00 $171.00 $30.00 $141.00 $234.00 $60.00 $174.00 $177.00 $72.00 $105.00 $174.00 $70.00

$591.00 $184.00 $110.00 $74.00 --------$167.00 --------$28.00 ----------------$125.00 $316.00 $283.00 $33.00 $10.00 ----------------$69.00 NC NC NC NC NC NC NC $19.00 $30.00 ------------------------$225.00 $49.00 $175.00 $154.00 $33.00 $121.00 $232.00 $58.00 $174.00 $173.00 $31.00 $142.00 $237.00 $62.00 $175.00 $181.00 $76.00 $105.00 $177.00 $72.00

$502.00 $173.00 $105.00 $68.00 --------$159.00 --------$26.00 ----------------$115.00 $300.00 $270.00 $30.00 $9.00 ----------------$53.00 NC NC NC NC NC NC NC $10.00 $16.00 ------------------------$207.00 $45.00 $162.00 $141.00 $29.00 $112.00 $215.00 $53.00 $162.00 $160.00 $29.00 $131.00 $220.00 $58.00 $162.00 $166.00 $69.00 $97.00 $165.00 $67.00

$538.00 $181.00 $108.00 $73.00 --------$164.00 --------$28.00 ----------------$124.00 $310.00 $278.00 $32.00 $9.00 ----------------$55.00 NC NC NC NC NC NC NC $10.00 $16.00 ------------------------$221.00 $47.00 $174.00 $151.00 $31.00 $120.00 $229.00 $56.00 $173.00 $171.00 $30.00 $141.00 $234.00 $60.00 $174.00 $177.00 $72.00 $105.00 $174.00 $70.00

$591.00 $184.00 $110.00 $74.00 --------$167.00 --------$28.00 ----------------$125.00 $316.00 $283.00 $33.00 $10.00 ----------------$58.00 NC NC NC NC NC NC NC $11.00 $17.00 ------------------------$225.00 $49.00 $175.00 $154.00 $33.00 $121.00 $232.00 $58.00 $174.00 $173.00 $31.00 $142.00 $237.00 $62.00 $175.00 $181.00 $76.00 $105.00 $177.00 $72.00


Part C, 393


Medicine CPT Code

2003 MRA


--------$60.00 $16.00 $44.00 $112.00 $28.00 $85.00 $122.00 $31.00 $92.00 $175.00 $31.00 $144.00 $117.00 $21.00 $96.00 $174.00 $26.00 $150.00 $118.00 $17.00 $101.00 $63.00 $26.00 $42.00 $189.00 $36.00 $154.00 $121.00 $23.00 $96.00 $277.00 $89.00 $181.00 $184.00 $59.00 $121.00 $177.00 $34.00 $143.00 $122.00 $23.00 $98.00 $183.00 $65.00 $105.00 $148.00 $25.00 $124.00 ---------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$97.00 $97.00 $14.00 $82.00 $151.00 $26.00 $125.00 $189.00 $28.00 $160.00 $206.00 $44.00 $162.00 $167.00 $28.00 $139.00 $208.00 $45.00 $162.00 $141.00 $28.00 $112.00 $130.00 $20.00 $110.00 $201.00 $39.00 $162.00 $131.00 $25.00 $106.00 $227.00 $66.00 $162.00 $178.00 $45.00 $132.00 $208.00 $46.00 $162.00 $131.00 $28.00 $103.00 $132.00 $68.00 $64.00 $80.00 $25.00 $55.00 $47.00

$105.00 $103.00 $15.00 $88.00 $161.00 $27.00 $134.00 $202.00 $30.00 $172.00 $220.00 $46.00 $173.00 $178.00 $29.00 $149.00 $222.00 $47.00 $174.00 $150.00 $30.00 $121.00 $139.00 $21.00 $118.00 $215.00 $41.00 $174.00 $140.00 $27.00 $113.00 $242.00 $68.00 $173.00 $189.00 $47.00 $142.00 $222.00 $48.00 $174.00 $140.00 $30.00 $110.00 $139.00 $70.00 $68.00 $85.00 $26.00 $59.00 $50.00

$105.00 $105.00 $16.00 $89.00 $164.00 $28.00 $135.00 $204.00 $31.00 $173.00 $222.00 $48.00 $174.00 $181.00 $30.00 $150.00 $225.00 $50.00 $175.00 $153.00 $31.00 $121.00 $141.00 $22.00 $119.00 $218.00 $43.00 $175.00 $142.00 $28.00 $114.00 $246.00 $71.00 $174.00 $191.00 $48.00 $143.00 $226.00 $51.00 $175.00 $143.00 $32.00 $111.00 $141.00 $72.00 $69.00 $87.00 $28.00 $60.00 $52.00

$97.00 $97.00 $14.00 $82.00 $151.00 $26.00 $125.00 $189.00 $28.00 $160.00 $206.00 $44.00 $162.00 $167.00 $28.00 $139.00 $208.00 $45.00 $162.00 $141.00 $28.00 $112.00 $130.00 $20.00 $110.00 $201.00 $39.00 $162.00 $131.00 $25.00 $106.00 $227.00 $66.00 $162.00 $178.00 $45.00 $132.00 $208.00 $46.00 $162.00 $131.00 $28.00 $103.00 $132.00 $68.00 $64.00 $80.00 $25.00 $55.00 $47.00

$105.00 $103.00 $15.00 $88.00 $161.00 $27.00 $134.00 $202.00 $30.00 $172.00 $220.00 $46.00 $173.00 $178.00 $29.00 $149.00 $222.00 $47.00 $174.00 $150.00 $30.00 $121.00 $139.00 $21.00 $118.00 $215.00 $41.00 $174.00 $140.00 $27.00 $113.00 $242.00 $68.00 $173.00 $189.00 $47.00 $142.00 $222.00 $48.00 $174.00 $140.00 $30.00 $110.00 $139.00 $70.00 $68.00 $85.00 $26.00 $59.00 $50.00

$105.00 $105.00 $16.00 $89.00 $164.00 $28.00 $135.00 $204.00 $31.00 $173.00 $222.00 $48.00 $174.00 $181.00 $30.00 $150.00 $225.00 $50.00 $175.00 $153.00 $31.00 $121.00 $141.00 $22.00 $119.00 $218.00 $43.00 $175.00 $142.00 $28.00 $114.00 $246.00 $71.00 $174.00 $191.00 $48.00 $143.00 $226.00 $51.00 $175.00 $143.00 $32.00 $111.00 $141.00 $72.00 $69.00 $87.00 $28.00 $60.00 $52.00


Part C, 394


Medicine CPT Code

2003 MRA

93990 93990-26 93990-TC 94002 94003 94004 94010 94010-26 94010-TC 94014 94015 94016 94060 94060-26 94060-TC 94070 94070-26 94070-TC 94150 94150-26 94150-TC 94200 94200-26 94200-TC 94250 94250-26 94250-TC 94375 94375-26 94375-TC 94400 94400-26 94400-TC 94450 94450-26 94450-TC 94452 94452-26 94452-TC 94453 94453-26 94453-TC 94610 94620 94620-26 94620-TC 94621 94621-26 94621-TC 94640

$110.00 $14.00 $96.00 ------------------------$30.00 $12.00 $16.00 $39.00 $14.00 $26.00 $57.00 $18.00 $36.00 $32.00 $11.00 $19.00 $8.00 $6.00 $3.00 $17.00 $7.00 $9.00 $12.00 $8.00 $5.00 $34.00 $16.00 $17.00 $40.00 $24.00 $14.00 $37.00 $20.00 $15.00 --------------------------------------------------------$91.00 $38.00 $54.00 $122.00 $71.00 $52.00 $19.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$126.00 $29.00 $97.00 $105.00 $76.00 $55.00 $39.00 $9.00 $30.00 $61.00 $33.00 $28.00 $66.00 $15.00 $51.00 $65.00 $32.00 $33.00 $27.00 $4.00 $23.00 $27.00 $6.00 $21.00 $28.00 $6.00 $22.00 $43.00 $17.00 $26.00 $61.00 $22.00 $39.00 $74.00 $22.00 $52.00 $62.00 $16.00 $46.00 $86.00 $21.00 $65.00 $67.00 $62.00 $34.00 $27.00 $178.00 $77.00 $101.00 $20.00

$134.00 $30.00 $104.00 $109.00 $78.00 $57.00 $42.00 $10.00 $32.00 $65.00 $36.00 $29.00 $70.00 $15.00 $55.00 $69.00 $33.00 $36.00 $29.00 $5.00 $25.00 $29.00 $7.00 $23.00 $30.00 $6.00 $24.00 $45.00 $17.00 $28.00 $64.00 $23.00 $42.00 $79.00 $23.00 $55.00 $66.00 $17.00 $50.00 $92.00 $22.00 $70.00 $69.00 $65.00 $35.00 $29.00 $188.00 $79.00 $108.00 $21.00

$138.00 $33.00 $105.00 $114.00 $82.00 $59.00 $42.00 $10.00 $32.00 $66.00 $36.00 $30.00 $71.00 $15.00 $55.00 $70.00 $34.00 $36.00 $30.00 $5.00 $25.00 $30.00 $7.00 $23.00 $31.00 $7.00 $25.00 $46.00 $17.00 $29.00 $65.00 $23.00 $42.00 $80.00 $24.00 $56.00 $67.00 $17.00 $50.00 $93.00 $23.00 $71.00 $71.00 $66.00 $36.00 $30.00 $191.00 $81.00 $109.00 $22.00

$126.00 $29.00 $97.00 $105.00 $76.00 $55.00 $39.00 $9.00 $30.00 $61.00 $33.00 $28.00 $66.00 $15.00 $51.00 $65.00 $32.00 $33.00 $27.00 $4.00 $23.00 $27.00 $6.00 $21.00 $28.00 $6.00 $22.00 $43.00 $17.00 $26.00 $61.00 $22.00 $39.00 $74.00 $22.00 $52.00 $62.00 $16.00 $46.00 $86.00 $21.00 $65.00 $67.00 $62.00 $34.00 $27.00 $178.00 $77.00 $101.00 $20.00

$134.00 $30.00 $104.00 $109.00 $78.00 $57.00 $42.00 $10.00 $32.00 $65.00 $36.00 $29.00 $70.00 $15.00 $55.00 $69.00 $33.00 $36.00 $29.00 $5.00 $25.00 $29.00 $7.00 $23.00 $30.00 $6.00 $24.00 $45.00 $17.00 $28.00 $64.00 $23.00 $42.00 $79.00 $23.00 $55.00 $66.00 $17.00 $50.00 $92.00 $22.00 $70.00 $69.00 $65.00 $35.00 $29.00 $188.00 $79.00 $108.00 $21.00

$138.00 $33.00 $105.00 $114.00 $82.00 $59.00 $42.00 $10.00 $32.00 $66.00 $36.00 $30.00 $71.00 $15.00 $55.00 $70.00 $34.00 $36.00 $30.00 $5.00 $25.00 $30.00 $7.00 $23.00 $31.00 $7.00 $25.00 $46.00 $17.00 $29.00 $65.00 $23.00 $42.00 $80.00 $24.00 $56.00 $67.00 $17.00 $50.00 $93.00 $23.00 $71.00 $71.00 $66.00 $36.00 $30.00 $191.00 $81.00 $109.00 $22.00


Part C, 395


Medicine CPT Code

2003 MRA

94642 94644 94645 94660 94662 94664 94667 94668 94669 94680 94680-26 94680-TC 94681 94681-26 94681-TC 94690 94690-26 94690-TC 94726 94726-26 94726-TC 94727 94727-26 94727-TC 94728 94728-26 94728-TC 94729 94729-26 94729-TC 94750 94750-26 94750-TC 94760 94761 94762 94770 94770-26 94770-TC 94799 94799-26 94799-TC 95004 95012 95017 95018 95024 95027 95028 95044

BR ----------------$54.00 $38.00 $18.00 $23.00 $16.00 --------$47.00 $23.00 $22.00 $60.00 $12.00 $43.00 $24.00 $4.00 $20.00 ------------------------------------------------------------------------------------------------$37.00 $14.00 $21.00 $9.00 $20.00 $30.00 $21.00 $9.00 $12.00 BR BR BR $3.00 ------------------------$3.00 $5.00 $8.00 $7.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

--------$47.00 $15.00 $70.00 $42.00 $19.00 $28.00 $31.00 $35.00 $62.00 $14.00 $48.00 $57.00 $11.00 $46.00 $54.00 $4.00 $49.00 $57.00 $14.00 $43.00 $46.00 $14.00 $32.00 $44.00 $14.00 $30.00 $59.00 $10.00 $49.00 $87.00 $13.00 $74.00 $4.00 $5.00 $26.00 $8.00 ----------------------------------------$7.00 $21.00 $9.00 $22.00 $8.00 $5.00 $15.00 $6.00

--------$51.00 $16.00 $73.00 $44.00 $20.00 $31.00 $34.00 $38.00 $66.00 $15.00 $51.00 $61.00 $11.00 $49.00 $58.00 $5.00 $53.00 $61.00 $14.00 $47.00 $49.00 $14.00 $34.00 $46.00 $15.00 $32.00 $63.00 $11.00 $52.00 $93.00 $13.00 $80.00 $4.00 $6.00 $28.00 $9.00 ----------------------------------------$8.00 $22.00 $9.00 $24.00 $9.00 $6.00 $16.00 $7.00

--------$51.00 $17.00 $75.00 $46.00 $21.00 $31.00 $35.00 $39.00 $67.00 $15.00 $52.00 $62.00 $12.00 $50.00 $58.00 $5.00 $53.00 $61.00 $14.00 $47.00 $49.00 $14.00 $35.00 $47.00 $15.00 $32.00 $64.00 $11.00 $53.00 $94.00 $13.00 $80.00 $4.00 $6.00 $29.00 $9.00 ----------------------------------------$8.00 $23.00 $9.00 $24.00 $10.00 $6.00 $16.00 $7.00

--------$47.00 $15.00 $43.00 $42.00 $19.00 $28.00 $31.00 $35.00 $62.00 $14.00 $48.00 $57.00 $11.00 $46.00 $54.00 $4.00 $49.00 $57.00 $14.00 $43.00 $46.00 $14.00 $32.00 $44.00 $14.00 $30.00 $59.00 $10.00 $49.00 $87.00 $13.00 $74.00 $4.00 $5.00 $26.00 $8.00 ----------------------------------------$7.00 $21.00 $4.00 $8.00 $1.00 $5.00 $15.00 $6.00

--------$51.00 $16.00 $45.00 $44.00 $20.00 $31.00 $34.00 $38.00 $66.00 $15.00 $51.00 $61.00 $11.00 $49.00 $58.00 $5.00 $53.00 $61.00 $14.00 $47.00 $49.00 $14.00 $34.00 $46.00 $15.00 $32.00 $63.00 $11.00 $52.00 $93.00 $13.00 $80.00 $4.00 $6.00 $28.00 $9.00 ----------------------------------------$8.00 $22.00 $4.00 $8.00 $1.00 $6.00 $16.00 $7.00

--------$51.00 $17.00 $46.00 $46.00 $21.00 $31.00 $35.00 $39.00 $67.00 $15.00 $52.00 $62.00 $12.00 $50.00 $58.00 $5.00 $53.00 $61.00 $14.00 $47.00 $49.00 $14.00 $35.00 $47.00 $15.00 $32.00 $64.00 $11.00 $53.00 $94.00 $13.00 $80.00 $4.00 $6.00 $29.00 $9.00 ----------------------------------------$8.00 $23.00 $5.00 $9.00 $2.00 $6.00 $16.00 $7.00


Part C, 396


Medicine CPT Code

2003 MRA

95052 95056 95060 95065 95070 95071 95076 95079 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 95250 95251 95803 95803-26 95803-TC 95805 95805-26 95805-TC 95806 95806-26 95806-TC 95807 95807-26 95807-TC 95808 95808-26 95808-TC 95810 95810-26 95810-TC 95811 95811-26 95811-TC

$9.00 $6.00 $13.00 $7.00 $82.00 $105.00 ----------------$10.00 $9.00 BR BR BR BR BR BR BR $9.00 $17.00 $24.00 $33.00 $32.00 $36.00 $7.00 $13.00 $103.00 BR $114.00 --------------------------------$334.00 $94.00 $237.00 $232.00 $109.00 $137.00 $367.00 $98.00 $256.00 $456.00 $149.00 $256.00 $521.00 $183.00 $256.00 $644.00 $196.00 $423.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$7.00 $48.00 $38.00 $27.00 $33.00 $38.00 $128.00 $91.00 $10.00 $11.00 --------------------------------------------------------$13.00 $23.00 $42.00 $38.00 $56.00 $75.00 $14.00 $10.00 $147.00 --------$169.00 $49.00 $153.00 $49.00 $104.00 $461.00 $66.00 $395.00 $183.00 $68.00 $115.00 $515.00 $70.00 $446.00 $679.00 $98.00 $581.00 $673.00 $136.00 $537.00 $708.00 $142.00 $566.00

$8.00 $51.00 $40.00 $29.00 $35.00 $41.00 $133.00 $95.00 $10.00 $12.00 --------------------------------------------------------$14.00 $25.00 $45.00 $40.00 $60.00 $81.00 $15.00 $11.00 $153.00 --------$182.00 $50.00 $163.00 $50.00 $112.00 $492.00 $68.00 $424.00 $193.00 $70.00 $123.00 $551.00 $72.00 $479.00 $726.00 $102.00 $624.00 $718.00 $140.00 $577.00 $755.00 $146.00 $608.00

$8.00 $52.00 $41.00 $30.00 $36.00 $41.00 $135.00 $96.00 $11.00 $12.00 --------------------------------------------------------$15.00 $25.00 $45.00 $41.00 $60.00 $81.00 $15.00 $11.00 $156.00 --------$184.00 $52.00 $164.00 $52.00 $113.00 $497.00 $70.00 $428.00 $195.00 $72.00 $124.00 $556.00 $74.00 $482.00 $733.00 $104.00 $629.00 $725.00 $144.00 $582.00 $763.00 $150.00 $613.00

$7.00 $48.00 $38.00 $27.00 $33.00 $38.00 $82.00 $75.00 $10.00 $11.00 --------------------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $113.00 --------$169.00 $49.00 $153.00 $49.00 $104.00 $461.00 $66.00 $395.00 $183.00 $68.00 $115.00 $515.00 $70.00 $446.00 $679.00 $98.00 $581.00 $673.00 $136.00 $537.00 $708.00 $142.00 $566.00

$8.00 $51.00 $40.00 $29.00 $35.00 $41.00 $84.00 $77.00 $10.00 $12.00 --------------------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $116.00 --------$182.00 $50.00 $163.00 $50.00 $112.00 $492.00 $68.00 $424.00 $193.00 $70.00 $123.00 $551.00 $72.00 $479.00 $726.00 $102.00 $624.00 $718.00 $140.00 $577.00 $755.00 $146.00 $608.00

$8.00 $52.00 $41.00 $30.00 $36.00 $41.00 $86.00 $78.00 $11.00 $12.00 --------------------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $119.00 --------$184.00 $52.00 $164.00 $52.00 $113.00 $497.00 $70.00 $428.00 $195.00 $72.00 $124.00 $556.00 $74.00 $482.00 $733.00 $104.00 $629.00 $725.00 $144.00 $582.00 $763.00 $150.00 $613.00


Part C, 397


Medicine CPT Code

2003 MRA

95812 95812-26 95812-TC 95813 95813-26 95813-TC 95816 95816-26 95816-TC 95819 95819-26 95819-TC 95822 95822-26 95822-TC 95824 95824-26 95824-TC 95827 95827-26 95827-TC 95829 95829-26 95829-TC 95830 95831 95832 95833 95834 95851 95852 95857 95860 95860-26 95860-TC 95861 95861-26 95861-TC 95863 95863-26 95863-TC 95864 95864-26 95864-TC 95865 95865-26 95865-TC 95866 95866-26 95866-TC

$137.00 $58.00 $68.00 $177.00 $89.00 $68.00 $133.00 $54.00 $78.00 $115.00 $58.00 $56.00 $120.00 $58.00 $63.00 $51.00 $41.00 $10.00 $145.00 $59.00 $86.00 $328.00 $291.00 $6.00 $133.00 $26.00 $21.00 $34.00 $44.00 $18.00 $14.00 $40.00 $73.00 $53.00 $15.00 $113.00 $86.00 $28.00 $138.00 $102.00 $35.00 $177.00 $114.00 $67.00 -------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$376.00 $65.00 $311.00 $456.00 $103.00 $353.00 $390.00 $65.00 $326.00 $446.00 $65.00 $381.00 $402.00 $65.00 $337.00 --------$44.00 --------$750.00 $64.00 $686.00 $2,031.00 $380.00 $1,652.00 $267.00 $33.00 $32.00 $41.00 $56.00 $20.00 $18.00 $59.00 $133.00 $58.00 $75.00 $187.00 $93.00 $94.00 $232.00 $112.00 $120.00 $262.00 $122.00 $141.00 $158.00 $95.00 $63.00 $146.00 $75.00 $71.00

$401.00 $67.00 $334.00 $486.00 $107.00 $379.00 $417.00 $67.00 $350.00 $476.00 $67.00 $410.00 $429.00 $67.00 $362.00 --------$46.00 --------$804.00 $66.00 $737.00 $2,168.00 $396.00 $1,773.00 $284.00 $35.00 $34.00 $43.00 $59.00 $21.00 $19.00 $63.00 $140.00 $60.00 $81.00 $198.00 $96.00 $101.00 $245.00 $115.00 $129.00 $278.00 $126.00 $151.00 $167.00 $99.00 $68.00 $153.00 $77.00 $76.00

$405.00 $69.00 $336.00 $491.00 $110.00 $381.00 $420.00 $69.00 $352.00 $481.00 $69.00 $412.00 $433.00 $69.00 $364.00 --------$47.00 --------$811.00 $68.00 $743.00 $2,192.00 $412.00 $1,780.00 $289.00 $36.00 $36.00 $43.00 $61.00 $22.00 $19.00 $64.00 $142.00 $61.00 $81.00 $201.00 $99.00 $102.00 $248.00 $118.00 $130.00 $283.00 $131.00 $152.00 $171.00 $102.00 $69.00 $156.00 $79.00 $77.00

$376.00 $65.00 $311.00 $456.00 $103.00 $353.00 $390.00 $65.00 $326.00 $446.00 $65.00 $381.00 $402.00 $65.00 $337.00 --------$44.00 --------$750.00 $64.00 $686.00 $2,031.00 $380.00 $1,652.00 $104.00 $17.00 $18.00 $24.00 $35.00 $9.00 $7.00 $33.00 $133.00 $58.00 $75.00 $187.00 $93.00 $94.00 $232.00 $112.00 $120.00 $262.00 $122.00 $141.00 $158.00 $95.00 $63.00 $146.00 $75.00 $71.00

$401.00 $67.00 $334.00 $486.00 $107.00 $379.00 $417.00 $67.00 $350.00 $476.00 $67.00 $410.00 $429.00 $67.00 $362.00 --------$46.00 --------$804.00 $66.00 $737.00 $2,168.00 $396.00 $1,773.00 $108.00 $18.00 $19.00 $25.00 $36.00 $9.00 $7.00 $35.00 $140.00 $60.00 $81.00 $198.00 $96.00 $101.00 $245.00 $115.00 $129.00 $278.00 $126.00 $151.00 $167.00 $99.00 $68.00 $153.00 $77.00 $76.00

$405.00 $69.00 $336.00 $491.00 $110.00 $381.00 $420.00 $69.00 $352.00 $481.00 $69.00 $412.00 $433.00 $69.00 $364.00 --------$47.00 --------$811.00 $68.00 $743.00 $2,192.00 $412.00 $1,780.00 $112.00 $19.00 $20.00 $25.00 $38.00 $9.00 $7.00 $36.00 $142.00 $61.00 $81.00 $201.00 $99.00 $102.00 $248.00 $118.00 $130.00 $283.00 $131.00 $152.00 $171.00 $102.00 $69.00 $156.00 $79.00 $77.00


Part C, 398


Medicine CPT Code

2003 MRA


$66.00 $43.00 $21.00 $96.00 $71.00 $26.00 $29.00 $21.00 $8.00 $29.00 $21.00 $8.00 $104.00 $81.00 $22.00 ------------------------------------------------$43.00 $34.00 $7.00 -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$103.00 $47.00 $56.00 $145.00 $71.00 $74.00 $100.00 $22.00 $78.00 $100.00 $22.00 $78.00 $217.00 $172.00 $45.00 $79.00 $22.00 $57.00 $79.00 $22.00 $57.00 $136.00 $66.00 $70.00 $64.00 $21.00 $42.00 $99.00 $52.00 $48.00 $88.00 $43.00 $46.00 $75.00 $3.00 $72.00 $104.00 $60.00 $45.00 $130.00 $75.00 $55.00 $158.00 $90.00 $68.00 $210.00 $120.00 $91.00 $254.00 $150.00

$109.00 $48.00 $60.00 $153.00 $74.00 $79.00 $107.00 $23.00 $84.00 $107.00 $23.00 $84.00 $226.00 $178.00 $48.00 $84.00 $23.00 $61.00 $84.00 $23.00 $61.00 $144.00 $69.00 $75.00 $67.00 $22.00 $45.00 $105.00 $54.00 $51.00 $93.00 $44.00 $49.00 $81.00 $3.00 $77.00 $110.00 $62.00 $48.00 $136.00 $77.00 $59.00 $166.00 $93.00 $73.00 $221.00 $124.00 $97.00 $267.00 $155.00

$110.00 $50.00 $61.00 $156.00 $76.00 $80.00 $108.00 $24.00 $84.00 $108.00 $23.00 $85.00 $232.00 $183.00 $49.00 $85.00 $23.00 $61.00 $85.00 $24.00 $61.00 $147.00 $71.00 $76.00 $68.00 $23.00 $46.00 $106.00 $55.00 $51.00 $95.00 $45.00 $49.00 $82.00 $4.00 $78.00 $112.00 $63.00 $49.00 $139.00 $79.00 $60.00 $169.00 $95.00 $74.00 $225.00 $127.00 $98.00 $272.00 $159.00

$103.00 $47.00 $56.00 $145.00 $71.00 $74.00 $100.00 $22.00 $78.00 $100.00 $22.00 $78.00 $217.00 $172.00 $45.00 $79.00 $22.00 $57.00 $79.00 $22.00 $57.00 $136.00 $66.00 $70.00 $64.00 $21.00 $42.00 $99.00 $52.00 $48.00 $88.00 $43.00 $46.00 $75.00 $3.00 $72.00 $104.00 $60.00 $45.00 $130.00 $75.00 $55.00 $158.00 $90.00 $68.00 $210.00 $120.00 $91.00 $254.00 $150.00

$109.00 $48.00 $60.00 $153.00 $74.00 $79.00 $107.00 $23.00 $84.00 $107.00 $23.00 $84.00 $226.00 $178.00 $48.00 $84.00 $23.00 $61.00 $84.00 $23.00 $61.00 $144.00 $69.00 $75.00 $67.00 $22.00 $45.00 $105.00 $54.00 $51.00 $93.00 $44.00 $49.00 $81.00 $3.00 $77.00 $110.00 $62.00 $48.00 $136.00 $77.00 $59.00 $166.00 $93.00 $73.00 $221.00 $124.00 $97.00 $267.00 $155.00

$110.00 $50.00 $61.00 $156.00 $76.00 $80.00 $108.00 $24.00 $84.00 $108.00 $23.00 $85.00 $232.00 $183.00 $49.00 $85.00 $23.00 $61.00 $85.00 $24.00 $61.00 $147.00 $71.00 $76.00 $68.00 $23.00 $46.00 $106.00 $55.00 $51.00 $95.00 $45.00 $49.00 $82.00 $4.00 $78.00 $112.00 $63.00 $49.00 $139.00 $79.00 $60.00 $169.00 $95.00 $74.00 $225.00 $127.00 $98.00 $272.00 $159.00


Part C, 399


Medicine CPT Code

2003 MRA


--------------------------------------------------------$61.00 $46.00 $14.00 $65.00 $50.00 $14.00 $105.00 $47.00 $57.00 ------------------------$94.00 $53.00 $41.00 $66.00 $34.00 $34.00 $67.00 $34.00 $34.00 ------------------------------------------------$44.00 $25.00 $11.00 $62.00 $33.00 $30.00 $40.00 $31.00 $9.00 ---------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$104.00 $285.00 $178.00 $107.00 $326.00 $210.00 $116.00 $94.00 $51.00 $44.00 $110.00 $54.00 $56.00 $178.00 $52.00 $126.00 $164.00 $100.00 $63.00 $168.00 $32.00 $136.00 $149.00 $31.00 $118.00 $154.00 $31.00 $123.00 $244.00 $90.00 $154.00 $246.00 $91.00 $155.00 $139.00 $21.00 $119.00 $82.00 $35.00 $47.00 $89.00 $38.00 $50.00 $368.00 $52.00 $316.00 $541.00 $134.00 $407.00 $37.00

$112.00 $299.00 $184.00 $115.00 $342.00 $218.00 $124.00 $99.00 $52.00 $47.00 $116.00 $56.00 $60.00 $189.00 $54.00 $135.00 $172.00 $104.00 $68.00 $179.00 $33.00 $147.00 $159.00 $32.00 $127.00 $164.00 $32.00 $132.00 $258.00 $93.00 $165.00 $261.00 $94.00 $167.00 $149.00 $21.00 $128.00 $86.00 $36.00 $50.00 $94.00 $40.00 $54.00 $393.00 $53.00 $340.00 $576.00 $139.00 $437.00 $38.00

$113.00 $304.00 $189.00 $116.00 $348.00 $223.00 $125.00 $101.00 $54.00 $47.00 $118.00 $57.00 $60.00 $192.00 $56.00 $136.00 $176.00 $107.00 $69.00 $181.00 $34.00 $148.00 $160.00 $33.00 $128.00 $166.00 $33.00 $134.00 $262.00 $95.00 $166.00 $265.00 $97.00 $167.00 $150.00 $22.00 $128.00 $88.00 $37.00 $51.00 $95.00 $41.00 $54.00 $396.00 $55.00 $341.00 $582.00 $143.00 $440.00 $40.00

$104.00 $285.00 $178.00 $107.00 $326.00 $210.00 $116.00 $94.00 $51.00 $44.00 $110.00 $54.00 $56.00 $178.00 $52.00 $126.00 $164.00 $100.00 $63.00 $168.00 $32.00 $136.00 $149.00 $31.00 $118.00 $154.00 $31.00 $123.00 $244.00 $90.00 $154.00 $246.00 $91.00 $155.00 $139.00 $21.00 $119.00 $82.00 $35.00 $47.00 $89.00 $38.00 $50.00 $368.00 $52.00 $316.00 $541.00 $134.00 $407.00 $37.00

$112.00 $299.00 $184.00 $115.00 $342.00 $218.00 $124.00 $99.00 $52.00 $47.00 $116.00 $56.00 $60.00 $189.00 $54.00 $135.00 $172.00 $104.00 $68.00 $179.00 $33.00 $147.00 $159.00 $32.00 $127.00 $164.00 $32.00 $132.00 $258.00 $93.00 $165.00 $261.00 $94.00 $167.00 $149.00 $21.00 $128.00 $86.00 $36.00 $50.00 $94.00 $40.00 $54.00 $393.00 $53.00 $340.00 $576.00 $139.00 $437.00 $38.00

$113.00 $304.00 $189.00 $116.00 $348.00 $223.00 $125.00 $101.00 $54.00 $47.00 $118.00 $57.00 $60.00 $192.00 $56.00 $136.00 $176.00 $107.00 $69.00 $181.00 $34.00 $148.00 $160.00 $33.00 $128.00 $166.00 $33.00 $134.00 $262.00 $95.00 $166.00 $265.00 $97.00 $167.00 $150.00 $22.00 $128.00 $88.00 $37.00 $51.00 $95.00 $41.00 $54.00 $396.00 $55.00 $341.00 $582.00 $143.00 $440.00 $40.00


Part C, 400


Medicine CPT Code

2003 MRA

95950 95950-26 95950-TC 95951 95951-26 95951-TC 95953 95953-26 95953-TC 95954 95954-26 95954-TC 95955 95955-26 95955-TC 95956 95956-26 95956-TC 95957 95957-26 95957-TC 95958 95958-26 95958-TC 95961 95961-26 95961-TC 95962 95962-26 95962-TC 95965 95965-26 95965-TC 95966 95966-26 95966-TC 95967 95967-26 95967-TC 95970 95971 95972 95974 95975 95978 95979 95980 95981 95982 95990

$265.00 $84.00 $177.00 $34.00 $14.00 $20.00 $411.00 $165.00 $240.00 $208.00 $134.00 $23.00 $130.00 $59.00 $74.00 $541.00 $166.00 $314.00 $171.00 $104.00 $64.00 $296.00 $230.00 $66.00 $216.00 $166.00 $48.00 $227.00 $176.00 $48.00 BR $420.00 BR BR $210.00 BR BR $184.00 BR $22.00 $39.00 $78.00 $155.00 $88.00 ----------------------------------------$57.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$358.00 $90.00 $268.00 --------$358.00 --------$459.00 $184.00 $275.00 $488.00 $140.00 $349.00 $234.00 $61.00 $173.00 $1,767.00 $215.00 $1,553.00 $342.00 $118.00 $224.00 $624.00 $254.00 $370.00 $324.00 $183.00 $140.00 $289.00 $195.00 $94.00 --------$471.00 ----------------$238.00 ----------------$208.00 --------$74.00 $56.00 $65.00 $231.00 $125.00 $278.00 $121.00 $54.00 $35.00 $59.00 $98.00

$381.00 $93.00 $288.00 --------$371.00 --------$486.00 $191.00 $296.00 $519.00 $145.00 $375.00 $249.00 $63.00 $186.00 $1,891.00 $222.00 $1,668.00 $363.00 $122.00 $241.00 $662.00 $264.00 $398.00 $343.00 $192.00 $151.00 $304.00 $203.00 $101.00 --------$487.00 ----------------$247.00 ----------------$215.00 --------$78.00 $59.00 $68.00 $243.00 $131.00 $292.00 $127.00 $57.00 $37.00 $62.00 $106.00

$385.00 $95.00 $290.00 --------$381.00 --------$494.00 $196.00 $297.00 $526.00 $149.00 $377.00 $252.00 $65.00 $187.00 $1,907.00 $229.00 $1,679.00 $367.00 $125.00 $242.00 $674.00 $274.00 $401.00 $352.00 $201.00 $152.00 $311.00 $210.00 $101.00 --------$500.00 ----------------$254.00 ----------------$221.00 --------$80.00 $61.00 $71.00 $252.00 $135.00 $304.00 $131.00 $62.00 $39.00 $65.00 $107.00

$358.00 $90.00 $268.00 --------$358.00 --------$459.00 $184.00 $275.00 $488.00 $140.00 $349.00 $234.00 $61.00 $173.00 $1,767.00 $215.00 $1,553.00 $342.00 $118.00 $224.00 $624.00 $254.00 $370.00 $324.00 $183.00 $140.00 $289.00 $195.00 $94.00 --------$471.00 ----------------$238.00 ----------------$208.00 --------$27.00 $46.00 $47.00 $185.00 $105.00 $218.00 $101.00 $54.00 $20.00 $42.00 $98.00

$381.00 $93.00 $288.00 --------$371.00 --------$486.00 $191.00 $296.00 $519.00 $145.00 $375.00 $249.00 $63.00 $186.00 $1,891.00 $222.00 $1,668.00 $363.00 $122.00 $241.00 $662.00 $264.00 $398.00 $343.00 $192.00 $151.00 $304.00 $203.00 $101.00 --------$487.00 ----------------$247.00 ----------------$215.00 --------$28.00 $48.00 $49.00 $193.00 $109.00 $228.00 $106.00 $57.00 $21.00 $44.00 $106.00

$385.00 $95.00 $290.00 --------$381.00 --------$494.00 $196.00 $297.00 $526.00 $149.00 $377.00 $252.00 $65.00 $187.00 $1,907.00 $229.00 $1,679.00 $367.00 $125.00 $242.00 $674.00 $274.00 $401.00 $352.00 $201.00 $152.00 $311.00 $210.00 $101.00 --------$500.00 ----------------$254.00 ----------------$221.00 --------$29.00 $50.00 $52.00 $202.00 $114.00 $239.00 $110.00 $62.00 $23.00 $47.00 $107.00


Part C, 401


Medicine CPT Code

2003 MRA

95991 95992 95999 96000 96001 96002 96003 96004 96020 96020-26 96020-TC 96101 96102 96103 96105 96110 96111 96116 96118 96119 96120 96125 96127 96150 96151 96152 96153 96154 96155 96360 96361 96365 96366 96367 96368 96369 96370 96371 96372 96373 96374 96375 96401 96402 96405 96406 96409 96411 96413 96415

----------------BR $93.00 $111.00 $21.00 $20.00 $97.00 ------------------------------------------------$68.00 $88.00 $68.00 --------------------------------------------------------------------------------------------------------------------------------------------------------See formula --------------------------------------------------------$57.00 $86.00 ---------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$132.00 $48.00 --------$107.00 $121.00 $25.00 $19.00 $131.00 BR $183.00 BR $89.00 $69.00 $31.00 $118.00 $10.00 $144.00 $103.00 $108.00 $87.00 $53.00 $129.00 $6.00 $24.00 $23.00 $22.00 $5.00 $22.00 $25.00 $62.00 $17.00 $75.00 $20.00 $33.00 $22.00 $206.00 $16.00 $78.00 $27.00 $21.00 $61.00 $24.00 $80.00 $35.00 $89.00 $126.00 $119.00 $67.00 $146.00 $31.00

$140.00 $50.00 --------$111.00 $127.00 $25.00 $20.00 $136.00 BR $189.00 BR $91.00 $73.00 $32.00 $123.00 $10.00 $149.00 $107.00 $112.00 $92.00 $56.00 $134.00 $6.00 $25.00 $24.00 $23.00 $5.00 $22.00 $26.00 $66.00 $18.00 $80.00 $22.00 $35.00 $24.00 $220.00 $17.00 $83.00 $29.00 $22.00 $66.00 $26.00 $86.00 $37.00 $94.00 $134.00 $128.00 $72.00 $156.00 $33.00

$142.00 $51.00 --------$114.00 $134.00 $26.00 $20.00 $141.00 BR $194.00 BR $93.00 $74.00 $33.00 $126.00 $11.00 $153.00 $110.00 $114.00 $92.00 $57.00 $136.00 $7.00 $25.00 $24.00 $23.00 $6.00 $23.00 $27.00 $67.00 $18.00 $81.00 $22.00 $36.00 $24.00 $222.00 $17.00 $83.00 $29.00 $23.00 $67.00 $26.00 $88.00 $38.00 $95.00 $136.00 $131.00 $73.00 $159.00 $33.00

$45.00 $42.00 --------$107.00 $121.00 $25.00 $19.00 $131.00 BR $183.00 BR $89.00 $26.00 $30.00 $118.00 $10.00 $137.00 $97.00 $88.00 $26.00 $29.00 $129.00 $6.00 $24.00 $23.00 $22.00 $5.00 $21.00 $25.00 $62.00 $17.00 $75.00 $20.00 $33.00 $22.00 $206.00 $16.00 $78.00 $27.00 $21.00 $61.00 $24.00 $80.00 $35.00 $33.00 $52.00 $119.00 $67.00 $146.00 $31.00

$47.00 $43.00 --------$111.00 $127.00 $25.00 $20.00 $136.00 BR $189.00 BR $91.00 $27.00 $31.00 $123.00 $10.00 $141.00 $100.00 $90.00 $27.00 $30.00 $134.00 $6.00 $24.00 $23.00 $22.00 $5.00 $22.00 $26.00 $66.00 $18.00 $80.00 $22.00 $35.00 $24.00 $220.00 $17.00 $83.00 $29.00 $22.00 $66.00 $26.00 $86.00 $37.00 $35.00 $54.00 $128.00 $72.00 $156.00 $33.00

$48.00 $44.00 --------$114.00 $134.00 $26.00 $20.00 $141.00 BR $194.00 BR $93.00 $28.00 $33.00 $126.00 $11.00 $145.00 $103.00 $92.00 $28.00 $32.00 $136.00 $7.00 $25.00 $24.00 $23.00 $6.00 $23.00 $27.00 $67.00 $18.00 $81.00 $22.00 $36.00 $24.00 $222.00 $17.00 $83.00 $29.00 $23.00 $67.00 $26.00 $88.00 $38.00 $36.00 $56.00 $131.00 $73.00 $159.00 $33.00


Part C, 402



2003 MRA ----------------$46.00 $46.00 $17.00 $54.00 $156.00 --------$134.00 ------------------------$126.00 BR $62.00 $69.00 $38.00 $17.00 --------$21.00 $24.00 $53.00 $152.00 $155.00 $214.00 BR $62.00 $29.00 $62.00 $29.00 NC NC $10.00 $16.00 $14.00 $15.00 $10.00 $15.00 $10.00 $9.00 $10.00 $16.00 $16.00 $13.00 $11.00 $19.00 $15.00 $22.00 $23.00 $24.00

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$151.00 $67.00 $114.00 $182.00 $85.00 $195.00 $914.00 $218.00 $198.00 $148.00 $122.00 $27.00 $131.00 --------$144.00 $67.00 $31.00 $22.00 $67.00 $76.00 $97.00 $140.00 $169.00 $186.00 $258.00 --------$83.00 $46.00 $93.00 $57.00 BR BR $7.00 $18.00 $17.00 $21.00 $12.00 $25.00 $7.00 $7.00 $8.00 $21.00 $29.00 $20.00 $14.00 $36.00 --------$35.00 $37.00 $47.00

$163.00 $72.00 $122.00 $196.00 $91.00 $210.00 $981.00 $236.00 $210.00 $159.00 $131.00 $29.00 $139.00 --------$155.00 $71.00 $32.00 $24.00 $72.00 $82.00 $105.00 $150.00 $178.00 $196.00 $272.00 --------$86.00 $48.00 $97.00 $60.00 BR BR $7.00 $18.00 $18.00 $22.00 $13.00 $27.00 $8.00 $7.00 $9.00 $22.00 $30.00 $21.00 $15.00 $38.00 --------$37.00 $39.00 $49.00

$165.00 $74.00 $125.00 $200.00 $93.00 $215.00 $1,001.00 $245.00 $214.00 $162.00 $134.00 $29.00 $142.00 --------$156.00 $77.00 $33.00 $24.00 $73.00 $82.00 $105.00 $152.00 $181.00 $198.00 $276.00 --------$88.00 $48.00 $99.00 $61.00 BR BR $7.00 $19.00 $19.00 $22.00 $13.00 $27.00 $8.00 $7.00 $9.00 $22.00 $30.00 $21.00 $15.00 $38.00 --------$38.00 $39.00 $49.00

$151.00 $67.00 $114.00 $182.00 $85.00 $195.00 $163.00 $35.00 $91.00 $148.00 $122.00 $27.00 $47.00 --------$144.00 $67.00 $31.00 $22.00 $67.00 $76.00 $97.00 $140.00 $74.00 $84.00 $136.00 --------$83.00 $46.00 $93.00 $57.00 BR BR $7.00 $18.00 $17.00 $21.00 $12.00 $25.00 $7.00 $7.00 $8.00 $21.00 $29.00 $20.00 $14.00 $36.00 --------$35.00 $37.00 $47.00

$163.00 $72.00 $122.00 $196.00 $91.00 $210.00 $175.00 $40.00 $95.00 $159.00 $131.00 $29.00 $49.00 --------$155.00 $71.00 $32.00 $24.00 $72.00 $82.00 $105.00 $150.00 $77.00 $87.00 $141.00 --------$86.00 $48.00 $97.00 $60.00 BR BR $7.00 $18.00 $18.00 $22.00 $13.00 $27.00 $8.00 $7.00 $9.00 $22.00 $30.00 $21.00 $15.00 $38.00 --------$37.00 $39.00 $49.00

$165.00 $74.00 $125.00 $200.00 $93.00 $215.00 $192.00 $48.00 $98.00 $162.00 $134.00 $29.00 $51.00 --------$156.00 $77.00 $33.00 $24.00 $73.00 $82.00 $105.00 $152.00 $79.00 $89.00 $145.00 --------$88.00 $48.00 $99.00 $61.00 BR BR $7.00 $19.00 $19.00 $22.00 $13.00 $27.00 $8.00 $7.00 $9.00 $22.00 $30.00 $21.00 $15.00 $38.00 --------$38.00 $39.00 $49.00


Part C, 403



2003 MRA $21.00 $19.00 $15.00 $26.00 $18.00 $23.00 $17.00 $22.00 $22.00 $24.00 $23.00 $23.00 $17.00 $83.00 $41.00 ----------------BR ------------------------BR $48.00 --------------------------------BR $26.00 $17.00 $7.00 --------------------------------$54.00 $26.00 $54.00 $26.00 NC $32.00 NC $23.00 NC NC $32.00 NC $23.00 -----------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$31.00 $29.00 --------$33.00 $19.00 ----------------$38.00 $29.00 $32.00 $38.00 $33.00 $34.00 ----------------$81.00 $27.00 --------$45.00 $53.00 $128.00 BR --------$39.00 $41.00 $36.00 $51.00 --------$38.00 $33.00 $18.00 $40.00 $30.00 $43.00 $34.00 --------------------------------NC $50.00 NC $80.00 NC NC $45.00 NC $30.00 $30.00 $15.00

$32.00 $30.00 --------$34.00 $20.00 ----------------$40.00 $30.00 $33.00 $40.00 $34.00 $35.00 ----------------$86.00 $28.00 --------$47.00 $55.00 $137.00 BR --------$41.00 $43.00 $38.00 $54.00 --------$40.00 $34.00 $18.00 $42.00 $31.00 $45.00 $35.00 --------------------------------NC $53.00 NC $83.00 NC NC $46.00 NC $32.00 $33.00 $16.00

$33.00 $30.00 --------$34.00 $20.00 ----------------$40.00 $31.00 $33.00 $41.00 $35.00 $36.00 ----------------$87.00 $28.00 --------$48.00 $56.00 $137.00 BR --------$41.00 $44.00 $38.00 $55.00 --------$40.00 $35.00 $19.00 $43.00 $32.00 $46.00 $36.00 --------------------------------NC $54.00 NC $85.00 NC NC $47.00 NC $32.00 $33.00 $16.00

$31.00 $29.00 --------$33.00 $19.00 ----------------$38.00 $29.00 $32.00 $38.00 $33.00 $34.00 ----------------$26.00 $12.00 --------$28.00 $30.00 $18.00 BR --------$39.00 $41.00 $36.00 $51.00 --------$36.00 $30.00 $17.00 $34.00 $28.00 $37.00 $31.00 --------------------------------NC $40.00 NC $67.00 NC NC $38.00 NC $26.00 $30.00 $15.00

$32.00 $30.00 --------$34.00 $20.00 ----------------$40.00 $30.00 $33.00 $40.00 $34.00 $35.00 ----------------$27.00 $13.00 --------$29.00 $31.00 $18.00 BR --------$41.00 $43.00 $38.00 $54.00 --------$37.00 $32.00 $17.00 $36.00 $29.00 $38.00 $32.00 --------------------------------NC $42.00 NC $69.00 NC NC $39.00 NC $27.00 $33.00 $16.00

$33.00 $30.00 --------$34.00 $20.00 ----------------$40.00 $31.00 $33.00 $41.00 $35.00 $36.00 ----------------$27.00 $13.00 --------$29.00 $32.00 $18.00 BR --------$41.00 $44.00 $38.00 $55.00 --------$38.00 $32.00 $18.00 $37.00 $30.00 $40.00 $33.00 --------------------------------NC $43.00 NC $71.00 NC NC $40.00 NC $28.00 $33.00 $16.00


Part C, 404


Medicine CPT Code

2003 MRA

98962 99000 99001 99002 99026 99027 99070 99071 99075 99078 99082 99090 99172 99173 99174 99175 99183 99184 99190 99191 99192 99195 99199 G0101 G0102 G0104 G0105 G0105-53 G0106 G0106-26 G0106-TC G0108 G0109 G0117 G0118 G0120 G0120-26 G0120-TC G0121 G0121-53 G0122 G0122-26 G0122-TC G0128 G0166 G0179 G0180 G0181 G0182 G0237

--------$6.00 $4.00 $35.00 BR BR BR NC See 440.13 NC BR BR BR BR --------$53.00 $123.00 --------BR BR BR $16.00 NC -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$11.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $18.00 $125.00 $256.00 ------------------------$107.00 NC $42.00 $21.00 $182.00 $419.00 $209.00 $228.00 $56.00 $173.00 $58.00 $16.00 $59.00 $48.00 $231.00 $58.00 $173.00 $419.00 $209.00 $288.00 $55.00 $233.00 $8.00 $148.00 $45.00 $59.00 $119.00 $120.00 $11.00

$12.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $20.00 $131.00 $265.00 ------------------------$116.00 NC $45.00 $22.00 $195.00 $445.00 $222.00 $243.00 $57.00 $185.00 $61.00 $16.00 $62.00 $51.00 $246.00 $61.00 $185.00 $446.00 $222.00 $306.00 $56.00 $250.00 $9.00 $159.00 $47.00 $62.00 $125.00 $125.00 $12.00

$12.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $20.00 $139.00 $274.00 ------------------------$118.00 NC $46.00 $23.00 $199.00 $460.00 $229.00 $245.00 $59.00 $186.00 $62.00 $17.00 $63.00 $51.00 $250.00 $64.00 $186.00 $461.00 $229.00 $309.00 $57.00 $251.00 $10.00 $160.00 $48.00 $63.00 $128.00 $128.00 $12.00

$11.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $18.00 $125.00 $256.00 ------------------------$107.00 NC $31.00 $10.00 $65.00 $222.00 $112.00 $228.00 $56.00 $173.00 $58.00 $16.00 $59.00 $48.00 $231.00 $58.00 $173.00 $223.00 $111.00 $288.00 $55.00 $233.00 $8.00 $148.00 $45.00 $59.00 $119.00 $120.00 $11.00

$12.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $20.00 $131.00 $265.00 ------------------------$116.00 NC $33.00 $10.00 $68.00 $235.00 $118.00 $243.00 $57.00 $185.00 $61.00 $16.00 $62.00 $51.00 $246.00 $61.00 $185.00 $235.00 $117.00 $306.00 $56.00 $250.00 $9.00 $159.00 $47.00 $62.00 $125.00 $125.00 $12.00

$12.00 ------------------------------------------------NC --------NC ------------------------$4.00 BR $20.00 $139.00 $274.00 ------------------------$118.00 NC $34.00 $11.00 $72.00 $249.00 $125.00 $245.00 $59.00 $186.00 $62.00 $17.00 $63.00 $51.00 $250.00 $64.00 $186.00 $250.00 $125.00 $309.00 $57.00 $251.00 $10.00 $160.00 $48.00 $63.00 $128.00 $128.00 $12.00


Part C, 405


Medicine CPT Code

2003 MRA

G0238 G0239 G0248 G0249 G0250 G0268 G0270 G0271 G0277 G0281 G0283 G0329 G0403 G0404 G0405 G0422 G0423 G0424 G0453 G0454 G0459 G0473 G9157 G9187 P3001 Q0035 Q0035-26 Q0035-TC Q0091

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Locality 01/02

Locality 03

Locality 04

Locality 01/02

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

(Facility MRA)

(Facility MRA)

$11.00 $14.00 $119.00 $119.00 $10.00 $60.00 $33.00 $18.00 $48.00 $15.00 $15.00 $10.00 $19.00 $9.00 $9.00 $113.00 $113.00 $32.00 $37.00 $10.00 $46.00 $14.00 $110.00 $48.00 $36.00 $23.00 $10.00 $13.00 $49.00

$12.00 $15.00 $128.00 $128.00 $11.00 $63.00 $34.00 $18.00 $51.00 $16.00 $16.00 $11.00 $20.00 $10.00 $10.00 $118.00 $118.00 $34.00 $38.00 $11.00 $47.00 $14.00 $114.00 $52.00 $37.00 $24.00 $10.00 $14.00 $52.00

$13.00 $16.00 $129.00 $128.00 $11.00 $66.00 $35.00 $19.00 $52.00 $16.00 $16.00 $11.00 $20.00 $10.00 $10.00 $121.00 $121.00 $35.00 $40.00 $11.00 $48.00 $15.00 $119.00 $53.00 $38.00 $25.00 $11.00 $14.00 $53.00

$11.00 $14.00 $119.00 $119.00 $10.00 $39.00 $30.00 $17.00 $48.00 $15.00 $15.00 $10.00 $19.00 $9.00 $9.00 $113.00 $113.00 $15.00 $37.00 $10.00 $46.00 $13.00 $110.00 $48.00 $36.00 $23.00 $10.00 $13.00 $22.00

$12.00 $15.00 $128.00 $128.00 $11.00 $41.00 $32.00 $17.00 $51.00 $16.00 $16.00 $11.00 $20.00 $10.00 $10.00 $118.00 $118.00 $16.00 $38.00 $11.00 $47.00 $13.00 $114.00 $52.00 $37.00 $24.00 $10.00 $14.00 $23.00

$13.00 $16.00 $129.00 $128.00 $11.00 $44.00 $32.00 $18.00 $52.00 $16.00 $16.00 $11.00 $20.00 $10.00 $10.00 $121.00 $121.00 $17.00 $40.00 $11.00 $48.00 $14.00 $119.00 $53.00 $38.00 $25.00 $11.00 $14.00 $25.00


Part C, 406


Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99291 99292 99304 99305 99306 99307 99308

$35.00 $58.00 $58.00 $84.00 $84.00 $19.00 $31.00 $40.00 $40.00 $65.00 $65.00 $65.00 $109.00 $152.00 $66.00 $109.00 $152.00 ------------------------$33.00 $54.00 $77.00 $129.00 $173.00 $213.00 $66.00 $88.00 $54.00 $88.00 $117.00 $163.00 $212.00 $54.00 $70.00 $96.00 $138.00 $190.00 $18.00 $28.00 $60.00 $94.00 $103.00 $192.00 $95.00 -----------------------------------------

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$48.00 $82.00 $119.00 $182.00 $229.00 $22.00 $47.00 $80.00 $118.00 $159.00 $81.00 $111.00 $151.00 $206.00 $114.00 $153.00 $226.00 $44.00 $81.00 $117.00 $44.00 $80.00 $116.00 $149.00 $188.00 $242.00 $80.00 $119.00 $52.00 $99.00 $135.00 $202.00 $247.00 $55.00 $83.00 $128.00 $186.00 $224.00 $24.00 $47.00 $70.00 $133.00 $196.00 $306.00 $137.00 $102.00 $145.00 $184.00 $50.00 $77.00

$51.00 $86.00 $126.00 $191.00 $240.00 $23.00 $50.00 $84.00 $123.00 $167.00 $84.00 $116.00 $157.00 $214.00 $119.00 $159.00 $235.00 $46.00 $84.00 $121.00 $46.00 $83.00 $120.00 $155.00 $195.00 $252.00 $83.00 $124.00 $55.00 $103.00 $141.00 $211.00 $257.00 $56.00 $86.00 $132.00 $192.00 $232.00 $25.00 $49.00 $73.00 $138.00 $204.00 $320.00 $143.00 $106.00 $150.00 $191.00 $52.00 $80.00

$52.00 $89.00 $130.00 $198.00 $249.00 $23.00 $51.00 $86.00 $127.00 $171.00 $87.00 $120.00 $162.00 $222.00 $125.00 $166.00 $244.00 $48.00 $87.00 $125.00 $48.00 $86.00 $125.00 $162.00 $203.00 $261.00 $86.00 $127.00 $56.00 $105.00 $144.00 $216.00 $264.00 $58.00 $89.00 $136.00 $198.00 $240.00 $26.00 $51.00 $76.00 $145.00 $214.00 $332.00 $149.00 $109.00 $155.00 $197.00 $53.00 $82.00

$30.00 $56.00 $86.00 $146.00 $189.00 $10.00 $28.00 $57.00 $87.00 $124.00 $81.00 $111.00 $151.00 $206.00 $114.00 $153.00 $226.00 $44.00 $81.00 $117.00 $44.00 $80.00 $116.00 $149.00 $188.00 $242.00 $80.00 $119.00 $36.00 $76.00 $107.00 $171.00 $212.00 $55.00 $83.00 $128.00 $186.00 $224.00 $24.00 $47.00 $70.00 $133.00 $196.00 $251.00 $126.00 $102.00 $145.00 $184.00 $50.00 $77.00



Locality 04


$31.00 $59.00 $90.00 $152.00 $198.00 $11.00 $29.00 $59.00 $91.00 $129.00 $84.00 $116.00 $157.00 $214.00 $119.00 $159.00 $235.00 $46.00 $84.00 $121.00 $46.00 $83.00 $120.00 $155.00 $195.00 $252.00 $83.00 $124.00 $38.00 $79.00 $110.00 $177.00 $219.00 $56.00 $86.00 $132.00 $192.00 $232.00 $25.00 $49.00 $73.00 $138.00 $204.00 $261.00 $131.00 $106.00 $150.00 $191.00 $52.00 $80.00

$33.00 $61.00 $95.00 $159.00 $207.00 $11.00 $31.00 $61.00 $94.00 $133.00 $87.00 $120.00 $162.00 $222.00 $125.00 $166.00 $244.00 $48.00 $87.00 $125.00 $48.00 $86.00 $125.00 $162.00 $203.00 $261.00 $86.00 $127.00 $39.00 $81.00 $114.00 $183.00 $226.00 $58.00 $89.00 $136.00 $198.00 $240.00 $26.00 $51.00 $76.00 $145.00 $214.00 $273.00 $137.00 $109.00 $155.00 $197.00 $53.00 $82.00

Part C, 407


Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99406 99407 99408 99409 99415 99416 99450 99455 99456

----------------$60.00 $77.00 ------------------------------------------------------------------------------------------------$59.00 $85.00 $109.00 $160.00 $193.00 $46.00 $71.00 $107.00 $156.00 $106.00 $104.00 $87.00 $88.00 BR ----------------------------------------$75.00 $75.00 $75.00 $104.00 $75.00 $104.00 ------------------------------------------------NC $90.00 BR

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

$101.00 $150.00 $81.00 $117.00 $106.00 $62.00 $90.00 $155.00 $206.00 $241.00 $67.00 $106.00 $149.00 $214.00 $85.00 $120.00 $61.00 $88.00 $145.00 $203.00 $246.00 $62.00 $94.00 $142.00 $198.00 $111.00 $108.00 $102.00 $101.00 $68.00 $139.00 $48.00 $48.00 $63.00 $41.00 $77.00 $116.00 $77.00 $116.00 $77.00 $116.00 $16.00 $31.00 $39.00 $76.00 $10.00 $5.00 NC -----------------

$105.00 $157.00 $84.00 $122.00 $110.00 $64.00 $93.00 $160.00 $214.00 $250.00 $70.00 $110.00 $155.00 $223.00 $89.00 $125.00 $64.00 $91.00 $150.00 $210.00 $255.00 $64.00 $97.00 $148.00 $206.00 $116.00 $112.00 $106.00 $105.00 $71.00 $146.00 $50.00 $49.00 $65.00 $42.00 $81.00 $120.00 $81.00 $120.00 $81.00 $120.00 $16.00 $32.00 $40.00 $79.00 $10.00 $6.00 NC -----------------

$108.00 $162.00 $87.00 $126.00 $114.00 $66.00 $96.00 $166.00 $221.00 $258.00 $72.00 $113.00 $160.00 $230.00 $91.00 $128.00 $66.00 $94.00 $155.00 $218.00 $264.00 $66.00 $101.00 $153.00 $213.00 $120.00 $116.00 $109.00 $109.00 $73.00 $149.00 $51.00 $51.00 $67.00 $44.00 $83.00 $124.00 $83.00 $124.00 $83.00 $124.00 $17.00 $33.00 $42.00 $81.00 $11.00 $6.00 NC -----------------

$101.00 $150.00 $81.00 $117.00 $106.00 $62.00 $90.00 $155.00 $206.00 $241.00 $67.00 $106.00 $149.00 $214.00 $85.00 $120.00 $61.00 $88.00 $145.00 $203.00 $246.00 $62.00 $94.00 $142.00 $198.00 $104.00 $101.00 $102.00 $101.00 $68.00 $94.00 $36.00 $47.00 $63.00 $41.00 $63.00 $98.00 $63.00 $98.00 $63.00 $98.00 $14.00 $29.00 $37.00 $74.00 $10.00 $5.00 NC -----------------



Locality 04


$105.00 $157.00 $84.00 $122.00 $110.00 $64.00 $93.00 $160.00 $214.00 $250.00 $70.00 $110.00 $155.00 $223.00 $89.00 $125.00 $64.00 $91.00 $150.00 $210.00 $255.00 $64.00 $97.00 $148.00 $206.00 $108.00 $104.00 $106.00 $105.00 $71.00 $97.00 $37.00 $48.00 $65.00 $42.00 $65.00 $102.00 $65.00 $102.00 $65.00 $102.00 $14.00 $30.00 $38.00 $77.00 $10.00 $6.00 NC -----------------

$108.00 $162.00 $87.00 $126.00 $114.00 $66.00 $96.00 $166.00 $221.00 $258.00 $72.00 $113.00 $160.00 $230.00 $91.00 $128.00 $66.00 $94.00 $155.00 $218.00 $264.00 $66.00 $101.00 $153.00 $213.00 $112.00 $108.00 $109.00 $109.00 $73.00 $100.00 $38.00 $50.00 $67.00 $44.00 $67.00 $105.00 $67.00 $105.00 $67.00 $105.00 $15.00 $31.00 $40.00 $79.00 $11.00 $6.00 NC -----------------

Part C, 408


Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99457 99487 99489 99490 99495 99496 99497 99498 99499 99600 G0245 G0246 G0296 G0337 G0372 G0396 G0397 G0402 G0406 G0407 G0408 G0409

----------------------------------------------------------------BR BR -------------------------------------------------------------------------------------------------

Locality 03

Locality 04

(Non-Facility MRA)

(Non-Facility MRA)

(Non-Facility MRA)

(Facility MRA)

BR BR BR $45.00 $180.00 $254.00 $95.00 $83.00 ----------------$73.00 $42.00 $31.00 $80.00 $10.00 $40.00 $79.00 $183.00 $43.00 $79.00 $114.00 $13.00

BR BR BR $47.00 $188.00 $266.00 $98.00 $86.00 ----------------$76.00 $44.00 $33.00 $83.00 $10.00 $41.00 $82.00 $191.00 $45.00 $82.00 $118.00 $14.00

BR BR BR $48.00 $193.00 $272.00 $101.00 $89.00 ----------------$78.00 $45.00 $34.00 $86.00 $11.00 $43.00 $85.00 $196.00 $47.00 $84.00 $121.00 $14.00

BR BR BR $35.00 $123.00 $178.00 $88.00 $82.00 ----------------$48.00 $24.00 $30.00 $80.00 $10.00 $38.00 $77.00 $141.00 $43.00 $79.00 $114.00 $13.00



Locality 04


BR BR BR $36.00 $127.00 $184.00 $91.00 $85.00 ----------------$50.00 $25.00 $31.00 $83.00 $10.00 $39.00 $79.00 $146.00 $45.00 $82.00 $118.00 $14.00

BR BR BR $37.00 $131.00 $190.00 $94.00 $89.00 ----------------$52.00 $26.00 $32.00 $86.00 $11.00 $40.00 $82.00 $151.00 $47.00 $84.00 $121.00 $14.00

Part C, 409

Chapter 4 Billing Instructions and Forms 3B

Bill Submission/Filing and Reporting Requirements 42B

Carrier Responsibilities

A carrier is responsible for meeting its obligations under this Rule regardless of any business arrangements with any service company/TPA, submitter, or any entity acting behalf of the carrier under which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division. At the time of authorization for medical service(s) or upon receipt of notification of emergency care, a carrier must notify each health care provider in writing, of additional form completion requirements or supporting documentation that are necessary for reimbursement determinations that are in addition to the requirements of this Manual and Rule 69L-7.740, F.A.C. At the time of authorization for medical service(s), or upon receipt of notification of emergency care, a carrier must inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Manual and Rule 69L-7.740, F.A.C., and provide in-state and out-ofstate health care providers the specific address for submitting a reimbursement request.

Provider Responsibilities

All health care providers are required to meet their obligations under this Rule, regardless of any business arrangement with any entity under which medical bills are prepared, processed or submitted to the carrier.

Billing When Paid Under Payment Plan(s)

Health care providers receiving reimbursement under any payment plans (pre-payment, prospective payment, or capitation, etc.) are required to accurately complete the Form DFS-F5-DWC-9 and submit the form to the carrier for all services rendered to injured workers.

2016 Edition

Page 410


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Additional Information Requested by Carrier

All health care providers are required to submit any additional form completion information and supporting documentation requested in writing, by the carrier at the time of authorization.

Bill Completion

Bills must be legibly and accurately completed by all health care providers. A carrier can require a health care provider or other recognized practitioner to complete additional data elements that are not required by the Division on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5DWC-90 if requested by the carrier at the time of authorization.

Form DFS-F5-DWC-25

Physicians must utilize only the Form DFS-F5-DWC-25 to request authorization for treatment and to report the injured worker’s medical treatment/status.:  No other reporting forms may be used in lieu of, or supplemental to, the Form DFS-F5-DWC-25.  Failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the instructions provided in this Manual, may result in the Division imposing sanctions or penalties pursuant to subsection 440.13(8), F.S., or subsection 440.13(11) F.S.  Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.  All information submitted on physician notes, medical records, medical records or Division-required medical reports must be consistent with information documented on the DFS-F5-DWC-25.  Carriers must utilize the information submitted on the DWC-25 form to monitor the medical necessity of services provided and services requested based on the medical condition being treated during the authorization process. Note: Interactive Form DFS-F5-DWC-25 is available under the “Forms” section on the DWC website.

2016 Edition

Page 411


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Billing for a Compensable Injury

All medical bills and form(s) related to services rendered for a compensable injury must be submitted by a health care provider to the carrier, service company/TPA or any entity acting on behalf of the carrier, as a requirement for billing.

Methods for Billing

Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the carrier, service company/TPA or any entity acting on behalf of the carrier, provided the carrier agrees.

Bill Corrections

Health care providers are responsible for correcting and resubmitting any billing forms returned by the carrier, service company/TPA or any entity acting on behalf of the carrier.

Form DFS-F5-DWC-9 (CMS-1500) 43B

Recognized Practitioners Who Bill on the DFS-F5-DWC-9 (CMS 1500)

Recognized practitioners, except physician assistants, advanced registered nurse practitioners, certified registered nurse anesthetists and anesthesia assistants, who are salaried workers of an authorized treating physician and who render direct billable services for which reimbursement is sought from a carrier, service company/TPA or any entity acting on behalf of the carrier, service company/TPA, must report and bill for such services on a Form DFS-F5-DWC-9 by entering the employing physician’s Florida DOH license number in Field 33b on the Form DFS-F5-DWC-9.

Home Medical Equipment

Physicians, physician assistants and ARNPs billing for Home Medical Equipment must enter the applicable HCPCS code in Field 24D and attach documentation indicating the cost of the supply.

2016 Edition

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Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Form DFS-F5-DWC-9 (CMS-1500), continued Dispensing Prescription Medications

Physicians, Physician Assistants and ARNPs must enter the NDC number in the universal 5-4-2 format in Form Field 24D with each segment separated by a dash (-). The Workers’ Compensation Unique code DSPNS is billed in addition to the NDC code in Field 24D if the drug is dispensed from the practitioner’s office for the injured worker’s use at home.

Compounded Drugs

When a physician or pharmacist compounds a drug that is not commercially available for prescription use by the worker at home, the physician or pharmacist may bill with the Workers’ Compensation Unique code COMPD in Field 24D. The individual component drugs used in compounding are to be identified by the NDC numbers.

Administration of Injectable Medications

Health care providers must use the appropriate HCPCS code in Fields 24D when available. If no HCPCS code is available, use the NDC number in the universal NDC 5-4-2 format in Field 24D.

Over-the-Counter Medications

Health care providers must use the appropriate HCPCS code in Field 24D when available. If no HCPCS code is available, use the NDC number in the universal 5-4-2 format in Field 24D.

Medication Management Therapy Sessions

Pharmacists who provide Medication Management Therapy Sessions that are ordered by a treating physician must bill by entering the appropriate CPT® code in Field 24D. Note: A copy of the physician’s written prescription order for Medication Management Therapy must be submitted with the bill for reimbursement.

Non-Physician Surgical Assistant

2016 Edition

A certified physician assistant or registered nurse first assistant who provides services as a surgical assistant, in lieu of a second physician, must enter the CPT® code(s) which represents the service(s) provided plus modifier AS in Field 24D.

Page 413


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Form DFS-F5-DWC-10 4B

Providers Who Bill on the DFS-F5-DWC-10

Pharmacists must bill using the Form DFS-F5-DWC-10 for pharmaceuticals and medical supplies prescribed by a physician or recognized practitioner. Medical Suppliers must bill using the Form DFS-F5-DWC-10 and are required to bill using HCPCS codes for medical supplies and equipment prescribed by a physician or recognized practitioner. Note: Pharmacists and Medical suppliers may only bill on an alternate to DFS-F5-DWC-10 when a carrier has pre-approved the use of an alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 must not be approved for use as an alternate form.

Billing Policy

Pharmacists must enter the NDC number, in the universal 5-4-2 format, in form Field 9.

Compounded Drugs

When a pharmacist compounds a drug that is not commercially available, the pharmacist must enter the Workers’ Compensation unique code COMPD in Field 9a of the DWC-10. The individual component drugs used in compounding must be identified by the NDC numbers in the universal 5-4-2 format.

Over the Counter Medications

Pharmacists must enter the NDC number, in the universal 5-4-2 format, in form Field 9a.

Home Medical Equipment

Pharmacists must enter the applicable HCPCS code(s) in Field 21 of the DFS-F5-DWC-10. Enter the quantity or units dispensed in Field 22. Home Medical Equipment Suppliers must enter the applicable HCPCS code(s) in Field 21. Enter quantity or units dispensed in Field 22. The license number of the pharmacist or the home medical supplier must be entered in Form Locator 29.

2016 Edition

Page 414


Appendix A: Workers’ Compensation Unique Procedure Codes DSPNS

Legend or prescription drugs dispensed by a licensed practitioner. (See Rule 69L-7.720(1), F.A.C., for the specific use of this code).

COMPD

Compounded drugs dispensed by a pharmacist or physician. (See Rule 69L-7.720(1), F.A.C., for the specific use of this code).

97260

Manipulation of spine by a physician other than an osteopathic or chiropractic physician.

97261

Manipulation of the temporomandibular joint; upper extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician.

97752

Muscle testing manually or by automated equipment with written report

97850

Physical reconditioning assessment; per hour

97851

Physical reconditioning assessment; additional thirty minutes

97852

Physical reconditioning program; per hour

97853

Physical reconditioning program; additional thirty minutes

99456

Independent Medical Examination

99456

CN Independent Medical Examination; cancelled less than 24 hours before appointment without good cause or failed to appear.

99457

Consensus Independent Medical Examination (CIME)

2016 Edition

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Appendix B Official Source for References As medical information pertaining to coding systems and policies are evolving, users of this manual seeking up-to-date information should use the appropriate listed reference address, telephone/fax number or web site for specific answers to questions, inquiries and products. ♦

Relative Value Guide: A Guide for Anesthesia Values American Society of Anesthesiologists 520 N. Northwest Highway Park Ridge, Il. 60068-2573 (847) 825-5586 Web Site: http://www.asahq.org

♦

Current Dental Procedure Codes (CDT) American Dental Association 211 East Chicago Avenue, 6th Floor Chicago, Illinois 60611-2678 (312) 440-2653 (800) 621-8099 (312) 440-7494 Fax Web site: www.ada.org ADA Order Department American Dental Association Post Office Box 776 St. Charles, Illinois 60174 (800) 947-4746 (888) 476-1880 Fax Web site link: ADA e Customer

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♦ MediSpan Wolters Kluwer Health, Inc. 8425 Woodfield Crossing Boulevard, Suite 490 Indianapolis, IN 46240 (855) 539-7686 (317) 735-5300 WebSite: www.wolterskluwer.com/Pages/Home.aspx

®

 Current Procedural Terminology, (CPT ) CPT® Assistant  Guide To The Evaluation of Permanent Impairment, 6th Edition  HCPCS®  ICD-9-CM®.ICD-10-CM®  National Physician Fee Schedule Relative Value File American Medical Association (AMA) – MAIN OFFICE 515 North State Street Chicago, Illinois 60610 (312) 464-5000 (312) 464-4184 Fax Web site: www.ama-assn.org AMA Order Department P.O. Box 930876 Atlanta, Georgia 31193-0876 (800) 621–8335 (800) 262-3211 (312) 464-5600 Fax ®

For questions regarding the use of CPT codes, please contact the American Medical ®

Association, CPT Information and Education Services, at 1-800-634-6922.

2016 Edition

Page 417



2016 Edition

Page 418


Appendix C Medicare Payment Localities (Counties)

Locality 01 / Locality 02: Franklin Lake Putnam Alachua Baker Gadsden Leon Santa Rosa Bay Gilchrist Levy Sarasota Bradford Glades Liberty Seminole Brevard Gulf Madison St. Johns Calhoun Hamilton Manatee Sumter Charlotte Hardee Marion Suwannee Citrus Hendry Nassau Taylor Clay Hernando Okaloosa Union Columbia Highlands Okeechobee Volusia De Soto Hillsborough Orange Wakulla Dixie Holmes Osceola Walton Duval Jackson Pasco Washington Escambia Jefferson Pinellas Flagler Lafayette Polk

Locality 03: Broward Collier Martin Indian River Lee Palm Beach St. Lucie

2016 Edition

Locality 04: Dade Monroe

Page 419


Appendix D Forms Note: The following Forms and Form Completion Instructions are incorporated by reference in Rule 69L-7.720, F.A.C. Forms Incorporated by Reference for Medical Billing, Filing and Reporting.     

Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Medical bill Form, Rev 02/12). Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form). Form DFS-F5-DWC-11 (American Dental Association Dental Medical bill Form, Rev. 2006). Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), Rev.2/14/06. Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006).

Form Completion Instructions are available at the following link: DWC website, Click on Chapter 69L-7.

2016 Edition

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Appendix E Definitions 1. “Add-on Code(s) means a procedure performed in addition to a primary procedure performed by the same physician. An ‘add-on’ code describes additional or supplemental procedure(s) associated with the primary service and are designated with a ‘+’ sign in the CPT® codebook. 2. “Ambulatory Surgical Center (ASC) means a health care facility as defined in s. 440.13(1)(f), F.S. 3. “Authorization” means the approval given to a health care provider by the carrier, self-insured employer or entity representing the

carrier or self-insured employer for the provision of medical services to an injured worker. 4. “Division” means the Division of Workers’ Compensation of the Department of Financial Services as defined in s. 440.02(14), F.S. 5. “Home Medical Equipment” is defined in s.400.925 (6) F.S. 6. “Home Medical Equipment provider” is defined in s.400.925 (7), F.S. 7. “Emergency Care and Services” means emergency services and care as defined in section 395.002, F.S. 8. “Health Care Provider” means a provider as defined in s.440.13 (1)(g), F.S. 9. “Home Health Agency” means an agency as defined in Chapter 400, Part III, F.S. 10. “Maximum Reimbursement Allowance (MRA)” means the specifically listed maximum dollar amount in the schedule adopted by the Three Member Panel for reimbursement of medical service(s) rendered to an injured worker by a health care provider. 11. “Medically Necessary or Medical Necessity” means any medical service or medical supply that satisfies the criteria for those terms as defined in paragraph 440.13(1)(k), F.S. 12. “Medical Record” means patient records maintained in accordance with the form and content required under Chapter 395, F.S.

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13. “Medical Record Review” means a review of the medical record of the injured worker in order to verify the medical necessity of the services and the care as they relate to the itemized statement for a specific bill. 14. “Modifier 51 Exempt” means a HCPCS Level II or CPT procedure code that does not require a modifier 51 or have multiple surgery pricing reduction applied for reimbursement. Note: See the CPT codebook for a list of “Modifier 51 Exempt” codes”. 15. “NDC Number” means the National Drug Code number as defined in paragraph 69L-7.710(1)(oo), F.A.C. 16. “Physician” means a physician as defined in s. 440.13(1) (p), F.S. 17. “Repackaged NDC number” means the National Drug Code number as defined in paragraph 69L-7.710(1)(oo), F.A.C. 18. “Unlisted Medication” means a medication which lacks assignment of a National Drug Code (NDC number) or a HCPCS procedure code.

2016 Edition

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Florida Workers’ Compensation

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